Sun28November0333PM 24

A 42-year-old woman presents with an acute attack of asthma. She is able to speak in short sentences.

Her respiratory rate is 28 breaths per minute and the peak expiratory flow rate 120 L/min (predicted 480 L/min).

Which is the most appropriate treatment for this patient?

(Please select 1 option)

Oral salbutamol

Intravenous aminophylline

Oral theophylline

Nebulised salbutamol Correct

Intravenous salbutamol

Explanation

This patient fits the criteria for acute severe asthma. In such cases, ß2-agonists should be administered as soon as possible, preferably nebulised driven by oxygen. Repeat doses should be given at 15-30 minute intervals, or continuous nebulisation can be used where there is inadequate response to bolus therapy. Nebulised ipratropium bromide should be added for patients with acute severe or life threatening asthma, or those with a poor initial response. Its addition produces significantly greater bronchodilation than a ß2-agonist alone.

Oxygen should be given to maintain saturations at 94-98%. Patients with saturations less than 92% on air should have an ABG to exclude hypercapnia. However, starting treatment should not be delayed to do the ABG. Initially, high-flow oxygen is used and then weaned to maintain adequate saturations. Unless you suspect COPD there is no need to be cautious with oxygen therapy.

Steroids reduce mortality, relapses, subsequent hospital admission, and requirement for ß2-agonists1. The earlier they are given in the attack, the better the outcome. A dose of 40-50 mg should therefore be given once oxygen and nebuliser therapy has been established. This should be continued for five days, or until recovery, and can then be stopped abruptly unless the patient has taken long-term oral corticosteroids.

Failure to respond to the above treatment steps may warrant the use of intravenous magnesium sulphate and aminophylline. However, these should not be used without discussion with your senior colleagues.

Intensive care is indicated for patients with severe acute or life threatening asthma who are failing to respond to therapy. Consider it in patients with deteriorating peak flow, persisting or worsening hypoxia, hypercapnia, acidosis, exhaustion, or altered conscious state. All patients who are transferred to an intensive care unit should be accompanied by a doctor who can intubate if necessary.

As an aside, chest radiographs are not indicated unless you suspect pneumothorax or consolidation, or there is life-threatening asthma, a failure to respond to treatment, or a need for ventilation.

Reference:

SIGN. British Guideline on the Management of Asthma.

Answer Statistics

1

1%

2

1%

3

99%

4

1%

Times answered: 299