Thu18November0755PM 1

An 18-year-old woman is admitted to the medical admissions unit with an attack of acute severe asthma.

Despite continuous nebulised ß2 agonist therapy and 40 mg prednisolone her respiratory rate is 25 breaths per minute, heart rate 110 beats per minute and SpO2 of 92% (FiO2 0.6).

What is the next most appropriate pharmacological therapeutic intervention?

(Please select 1 option)

Intravenous aminophylline

Intravenous magnesium sulphate Incorrect answer selected

Nebulised ipratropium bromide This is the correct answer

Intravenous ß2 agonist

Intravenous hydrocortisone

Explanation

Supplementary oxygen should be given to all hypoxic patients with acute severe asthma to maintain an SpO2 of 94-98%. High-dose inhaled ß2 agonists are first line agents in patients with acute severe asthma. Intravenous ß2 agonists should be reserved for those patients where inhaled therapy cannot be used reliably (patients in extremis or those being ventilated). Poor responders to an initial bolus of a nebulised ß2 agonist should be given continuous therapy.

Nebulised ipratropium bromide (0.5 mg given four to six hourly) should then be added to ß2 agonist therapy in patients with a poor initial response to treatment.

Steroids should be given in adequate doses in all cases of acute asthma attack. Prednisolone 40-50 mg daily for at least five days or until recovery or parenteral hydrocortisone 400 mg daily (100 mg six hourly) is as effective.

Magnesium sulphate (1.2-2 g IV infusion over 20 minutes) should be considered if there has not been a good initial response to bronchodilator therapy.

Intravenous aminophylline is not likely to result in any additional bronchodilatation compared to standard care with inhaled bronchodilators. It also has the potential to cause arrhythmias and vomiting.

Reference:

British Thoracic Society (BTS). Asthma Guideline.

Answer Statistics

1

2%

2

53%

3

44%

4

1%

5

2%

Times answered: 308