Case 1

John, a 38-year-old with a history of asthma since childhood, presents to the ED late in the evening complaining that his asthma has become worse during the day. He is able to complete sentences but feels breathlessness and has a tightness in his chest.

His observations are as follows:

• Pulse 104
• BP 120/80 mm Hg
• Respiratory rate (RR) 22 per min.
• Temperature 36.8°C
• Oxygen saturation of 96% on room air

An ECG is performed and is normal. His measured PEFR is 360L/min. and his best PEFR in the last year was 580L/min.

On general examination, you note that John is obese and has nicotine-stained fingers. You can hear good air entry throughout the chest and a widespread wheeze. No crepitations are heard and the percussion note is equally resonant all across the chest.

Categorise the severity of this asthma exacerbation using the information above:

John’s PEFR after the salbutamol (via a spacer) is 470 L/min.(80% best). He feels better and his symptoms of breathlessness and chest tightness have resolved. His observations are repeated and are as follows:

• Pulse 84
• BP 120/80 mm Hg
• Respiratory rate (RR) 18 per minute
• Oxygen saturation of 98% on room air

After a period of observation (2 hours) he remains stable (PEFR 80% best) and you plan to discharge him. You take a detailed medical history before considering discharge. List any factors that may lower your threshold for admitting a patient like John with moderately severe asthma.

John has no history of severe asthma and no adverse psychosocial factors are identified. 

Which one of the following actions is least appropriate as part of John’s discharge plan?