12.12.10 Acute respiratory compromise

History

    • Normal peak flow

    • DVT risk factors

    • Atopy

    • Pets

    • Temperature

    • Wheeze

    • Orthopnoea

    • Change in exercise tolerance

    • Smoking

BTS asthma guidelines

    • Near-fatal asthma

      • Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

    • Life threatening asthma

      • Clinical signs:

        • Altered conscious level

        • Exhaustion

        • Arrhythmia

        • Hypotension

        • Cyanosis

        • Silent chest

        • Poor respiratory effort

      • Measurements

        • “Normal” PaCO2 (4.6–6.0 kPa)

        • PaO2 <8 kPa

        • SpO2 <92%

        • PEF <33% best or predicted

    • Acute severe asthma

      • PEF 33-50% best or predicted

      • Respiratory rate ≥25/min

      • Heart rate ≥110/min

      • Inability to complete sentences in one breath

    • Moderate asthma exacerbation

      • Increasing symptoms

      • PEF >50-75% best or predicted

      • No features of acute severe asthma

    • Brittle asthma

      • Type 1: wide PEF variability (>40% diurnal variation for >50% of the time over a period >150 days) despite intense therapy

      • Type 2: sudden severe attacks on a background of apparently well controlled asthma

Management of acute asthma

    • Salbutamol

    • Atravent (ipratropium)

    • Steroids (oral, or IV if aspiration risk)

    • IV magnesium sulphate

    • Aminophyline

    • Intubation

CAP

    • Do a full septic screen as well as a CXR as there may be more than one site of infection

    • New AF on ECG?

      • No need to treat; should resolve

    • Urine altigens

      • Legionella

      • Pneumococcal

    • SIRS score >1 => Resus

Notes

    • SOB / DIB

    • Alteplase thrombolysis for COPD if within one hour

    • Surviving sepsis campaign => Antibiotics within an hour