Acute severe and life-threatening asthma — formative SAQs

SAQ 1 (10 marks)

A 7-year-old girl with known asthma is brought to the emergency department. Over the past day her wheeze and breathlessness have worsened despite frequent salbutamol at home. She can speak only in words, has marked subcostal and intercostal recession, a respiratory rate of 40 and heart rate of 150, and her oxygen saturation is 88% on air. She is alert but distressed, with a widespread expiratory wheeze. ^{[1] [5]}

1. State your assessment of severity and how you graded it. (3) ^[1]
2. Outline your initial management, including drugs and route. (4) ^{[2] [3]}
3. Describe how you would decide to escalate, and what you would do next. (3) ^[3]

Model answer — SAQ 1

(1) Severity (3). This is acute severe asthma: she can speak only in words, is hypoxaemic at 88% on air, has marked work of breathing with recession, and is tachypnoeic and tachycardic. I grade severity from the whole child — the ability to talk, the work of breathing, the oxygen saturation, the air entry and the conscious level — rather than any single number, and I would reassess after every intervention because a child can move into the life-threatening band within minutes. ^[1]

(2) Initial management (4). Sit her up, keep her calm, and give oxygen titrated to keep SpO2 at or above 94%. Start continuous (or back-to-back) nebulised salbutamol and add nebulised ipratropium 250 micrograms for this severe exacerbation, because continuous salbutamol beats intermittent dosing and adding ipratropium reduces admissions in severe disease. Give a systemic corticosteroid early — oral prednisolone 1–2 mg/kg (or IV methylprednisolone/hydrocortisone if not tolerated) — because the benefit takes hours to appear. Call for senior help and secure monitoring. ^{[2] [4]}

(3) Escalation (3). I would escalate if she fails to respond to continuous inhaled therapy — persisting hypoxaemia, ongoing marked work of breathing, or any life-threatening feature (silent chest, exhaustion, drowsiness, rising PaCO2). The first intravenous escalation is a single dose of intravenous magnesium sulfate; if she continues to deteriorate I would move to intravenous salbutamol and/or aminophylline in a monitored HDU or PICU setting with cardiac and electrolyte monitoring, involve anaesthetics and PICU early, and prepare for cautious ventilation. ^[3]