QuestionSBA
QuestionChoice
Inhaled corticosteroids will not provide immediate benefit to a patient presenting with an acute asthma flare-up. They have a role in long-term asthma control. They should be continued on the drug chart if a patient is admitted with an asthma flare-up and is already on them in the community; adding them in the acute setting will not provide significant rapid relief. Oral steroids are indicated in the management of acute asthma exacerbations. In the context of a raised PaCO<sub>2</sub>, this patient requires mechanical ventilation without delay.
52939
c
Add high-dose inhaled corticosteroids
QuestionChoice
A nasopharyngeal airway is an airway adjunct that will help maintain an airway at risk of obstruction/obstructed at the nasopharyngeal level. It does not provide definitive airway support and will not enable mechanical ventilation, which this tiring patient with asthma with a near-fatal flare-up requires at this stage.
52938
b
Insert a nasopharyngeal airway
QuestionChoice
This would be a sensible addition. However, this patient is tiring and so while magnesium may be provided, the next step should be summoning the intensive care team immediately with a view to intubation and ventilation before any further time is spent on medical management.
52940
d
Start a magnesium sulphate infusion
QuestionChoice
This patient has already had ipratropium bromide at the correct dose. Ipratropium is not provided back to back because it does not provide additional benefit in this manner and has anticholinergic side effects. The next dose would be due in 6-h time (500 μg 4 times a day). Furthermore, no additional time should be spent on medical management as a next step since seeking intensive care review with a view to intubation and ventilation is most important at this stage.
52941
e
Provide a further dose of nebulised ipratropium bromide
QuestionChoice
This patient has raised carbon dioxide levels, indicating that he is tiring. This represents a near-fatal asthma exacerbation. An intensive care review is now required since he will need intubation and ventilation. Practically, a 2222 call may need to be placed to summon the intensive care team immediately.
52937
a
Immediate intensive care review
Concept
Chapter
# Summary

Asthma is a common disease of the airways, involving reversible bronchoconstriction, hyperreactivity and chronic inflammation. When bronchoconstriction is triggered (an “asthma attack” or exacerbation), patients experience episodes of wheeze, dyspnoea, cough and chest tightness. Initial investigations in an asthma exacerbation include doing a peak flow measurement, an arterial blood gas (ABG) if oxygen saturations are low or hypercapnia is suspected, and a chest X-ray in selected cases (e.g. where there are signs of pneumonia). Management involves supplementary oxygen, bronchodilators (either inhaled or nebulised) and steroids. Patients with severe or life-threatening asthma exacerbations may require additional treatments including escalation to intensive care for intubation and ventilation in some cases.

# Definition

Asthma is a common disease in both adults and children, characterised by intermittent []()exacerbations with wheeze, cough, shortness of breath and chest tightness. There are several underlying mechanisms that centre around reversible bronchoconstriction, hyperreactivity and chronic inflammation.

# Epidemiology

In the UK, approximately 8 million people have been diagnosed with asthma, of which 5.4 million are on treatment. Onset is usually in childhood and some find symptoms remit with age, although relapse is possible after long periods of being well.

Asthma exacerbations are the cause of 60,000 hospital admissions per year in the UK. Over 1000 people die of asthma per year, with two-thirds of these deaths thought to be preventable. An estimated 7/10 people with asthma do not receive basic preventative care such as inhaler technique checks and a personalised asthma plan.

People experiencing socioeconomic deprivation are more likely to have asthma and to have worse outcomes (e.g. higher rates of hospitalisation). This is multifactorial, with these groups more likely to be exposed to triggers such as smoking and air pollution, and to have lower health literacy and access to healthcare.

# Aetiology

Asthma is often associated with a personal and/or family history of atopy, including the atopic triad of asthma, allergic rhinitis, and eczema. In asthma, there is an exaggerated response to a wide range of triggers. These include:

- Cold air and exercise
- Pollution and cigarette smoke
- Allergens such as animal dander, dust mites and pollen
- Irritants such as perfumes, paints or air fresheners
- Medications such as NSAIDs or beta-blockers

These trigger a type 1 hypersensitivity reaction which is mediated by IgE. T Helper 2 cells produce IL4, IL5 and IL13 cytokines which activate the humoral immune system, leading to the proliferation of eosinophils, mast cells and dendritic cells. These cells then produce more inflammatory mediators such as leukotrienes and histamine.

This inflammation contributes to airway hyperresponsiveness leading to bronchospasm, as well as mucus hypersecretion that also obstructs airways. Over time in severe asthma, airway remodelling mediated by fibroblasts causes chronic obstruction and thickening of smooth muscle.

# Classification

Acute asthma exacerbations are graded in severity as below:


| Severity | Clinical Features |
|-----------------------|-----------------------------------------------|
| Moderate | PEFR > 50% of predicted or best |
| | No features of severe/life-threatening asthma |
| Severe | PEFR 33-50% of predicted or best |
| | Heart rate > 110 |
| | Respiratory rate > 25 |
| | Unable to complete sentences in one breath |
| | Accessory muscle use |
| Life-threatening | PEFR < 33% of predicted or best |
| | Oxygen saturation < 92% or cyanosis |
| | Altered conciousness/confusion |
| | Exhaustion/poor respiratory effort |
| | Cardiac arrhythmia |
| | Hypotension |
| | Silent chest |
| Near fatal | Raised PaCO2 |
| | Requiring mechanical ventilation with raised inflation pressures |


# Signs and Symptoms

Patients experiencing an asthma exacerbation present with progressive worsening of the following symptoms, usually over the course of several hours:

- Wheeze
- Difficulty breathing
- Struggling to eat, speak or sleep due to breathlessness
- Cough
- Chest tightness
- Dizziness

On examination, patients may have:

- Tachypnoea
- Increased work of breathing
- Hyperinflated chest
- Expiratory polyphonic wheeze throughout the lung fields
- Decreased air entry 
- Cyanosis
- Tachycardia
- Altered mental state, e.g. drowsiness or confusion
- Exhaustion
- Hypotension

They may be able to identify a trigger and have signs and symptoms of this (e.g. fever and coryza in viral infection).


# Differential diagnosis

- **Pulmonary embolism** - associated with risk factors e.g. immobility, malignancy; shares features of shortness of breath and cough, may have haemoptysis and pleuritic chest pain.
- **Vocal cord dysfunction** - shares many triggers with asthma, inspiration more difficult than expiration, may have stridor.
- **Acute exacerbation of chronic obstructive pulmonary disease** - patients usually >35 years old with a significant smoking history, may overlap with asthma in some.
- **Gastro-oesophageal reflux disease** - microaspiration of stomach acid due to reflux can cause episodes of cough and wheeze which mimic asthma (although these may coexist and reflux can trigger asthma exacerbations). Symptoms are often postural and related to eating.
- **Anaphylaxis** - also may present with sudden-onset shortness of breath and wheeze, usually more rapid onset and may have skin and mucosal changes such as urticaria and lip swelling

# Investigations 

**Bedside tests:**

- **Peak expiratory flow rate (PEFR)** to help assess severity as per the classification above and monitor response to treatment.
- **Arterial blood gas** if the patient is hypoxic to assess oxygenation and ventilation in patients - CO2 is expected to be low due to hyperventilation and if this is raised this indicates the asthma attack is near fatal.
- **ECG** to look for arrhythmias especially if tachycardic.

**Blood tests:**

- **FBC** and **CRP** for inflammatory markers
- **U&Es** and **LFTs** as a baseline - patients may develop acute kidney injury if too breathless to drink for prolonged periods
- **Blood cultures** if bacterial infection suspected e.g. an unwell patient with fevers

**Imaging:**

- **Portable chest X-ray** if a trigger such as pneumonia or a complication such as pneumothorax is suspected clinically.

# Management 

- Recognise that this may be a medical emergency, assess using an ABCDE approach and escalate early to senior colleagues/critical care if not responding to treatment
- Titrate oxygen to maintain saturations of 94-98%
- Nebulised salbutamol (5mg) driven by oxygen (if out of hospital, give up to 10 puffs of inhaled salbutamol and call an ambulance if not responding)
- If the attack is severe or life-threatening or if response to salbutamol has been poor, add nebulised ipratropium bromide (500mcg 4-6 hourly)
- Give prednisolone 40-50 mg OD orally, or 100mg IV hydrocortisone QDS if the patient is unable to swallow
- Continue steroids for at least 5 days or until recovery (whichever is longer)
- Can consider IV magnesium sulphate (1.2-2 grams over 20 minutes) and/or aminophylline if the patient is not responding to nebulisers
- If the patient continues to deteriorate despite maximal therapy, they may require intubation and ventilation in an intensive care setting (for example in cases of severe hypoxia or exhaustion)
- Antibiotics should not be given routinely, especially as many infectious triggers of asthma exacerbations are viral

Follow up after an acute asthma attack is crucial, with NICE guidelines stating that patients should be reviewed within 2 days of discharge from hospital to assess their symptoms, inhaler technique and current management. Ensure all patients have an up-to-date personalised asthma action plan.

# Complications

- **Respiratory failure** which may be type 1 (hypoxaemia alone) or type 2 (hypoxaemia with hypercapnia)
- **Pneumothorax** - airway obstruction during asthma exacerbations may cause barotrauma and alveolar rupture, causing pneumothoraces or pneumomediastinum
- **Status asthmaticus** - repeated asthma attacks without recovery in between, or which do not respond to treatment
- **Death** - patients with previous severe asthma attacks and those adverse psychosocial factors are more likely to die of asthma (e.g. drug or alcohol abuse, repeated failure to attend appointments and learning difficulties)

# NICE Guidelines

[NICE CKS - Asthma](https://cks.nice.org.uk/topics/asthma/)

# References

[British Thoracic Society Asthma Guidelines](https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/)

[BNF - Acute Asthma](https://bnf.nice.org.uk/treatment-summaries/asthma-acute/)

[Report on health inequalities and asthma](https://www.asthmaandlung.org.uk/sites/default/files/2023-03/auk-health-inequalities-final.pdf)
2025
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In severe asthma exacerbations, rising carbon dioxide levels signal potential respiratory failure. Immediate intensive care review is crucial to provide interventions, support breathing, and prevent life-threatening complications from impaired gas exchange.
A 23-year-old man attends A&E with a 1-d history of shortness of breath. He reports no cough and no fever. He has a past medical history of asthma and takes a salbutamol and corticosteroid inhaler. On examination, his chest is diffusely wheezy with reduced air entry bilaterally. He ahs increased work of breathing. His vital signs are within normal parameters. He is commenced on back-to-back salbutamol and oral prednisolone. Nebulised ipratropium (500 μg) has also been provided. His arterial blood gases (ABGs) after an hour of medical therapy are shown below:


||||
|--------------|:-------:|------------------|
|pH|7.34|7.35 - 7.45|
|PaO₂|12.2 kPa|11 - 15|
|PaCO₂|6.5 kPa|4.6 - 6.4|
|Bicarbonate|23mmol/L|22 - 30|
|Base Excess|mmol/L|-2 to +2                  
O<sub>2</sub> saturation|99%|94-98%


What is the next step in his management?
a