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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
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