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