Case 3

Jane is a 37-year-old asthmatic who has been increasingly wheezy and breathless for 2 days. Her husband called an ambulance after finding her clammy and disorientated. She has been given oxygen and a salbutamol 5 mg nebuliser in the ambulance.

On arrival her observations are as follows:

• Pulse 122 irregular
• BP 96/72 mm Hg
• RR 36/minute
• Temperature 37.2 °C
• Oxygen sats. 90% on high-flow oxygen via facemask

On examination she is agitated, unable to speak and air entry is poor bilaterally. Her trachea is central.

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

List eight steps you would take in management of this patient over the next 15 minutes in the resuscitation room.

Jane is agitated and keeps pulling off her mask, which is making it difficult to gain intravenous access and apply monitoring.

Sedation of this patient is appropriate to facilitate management of this patient – true or false?

Jane's ECG demonstrates a sinus tachycardia with frequent atrial ectopic beats. The chest radiograph shows hyper-inflated lung fields with no pathological features.

Her husband says that her asthma used to be poorly controlled but that it has been much better in recent years. She is not pregnant. She is not normally on any medication other than her inhalers but she was involved in a road traffic collision a few days earlier and was discharged from a different ED with naproxen for muscular back and neck pain. She has been taking this regularly. You inform the husband that the naproxen could have contributed to the exacerbation and that when she recovers she should not take anti-inflammatory tablets again in the future.

She looks more exhausted despite your treatment plan and her arterial blood gas sample shows a reduced PaO₂ and a high PaCO₂. You are relieved to see the intensive care consultant enter the resuscitation room and expect him to intubate the patient. However, she suggests a trial on your BiPAP machine.

Is this management plan endorsed in the British asthma guidelines?