Acute Exacerbation

Bronchial Asthma
Case Presentation

Date : 26.6.2015 at 11 pm
54/M/MALE,

active smoker

K/C/O-

BA since childhood
- Schizophrenia

P/w-

SOB (worsen at 9 pm )
- Cough (unsure colour of sputum)
- Fever
*all Sx presence since 3 days

Rv Patient Medication :
On

T. Haloperidol 1.5mg BD
MDI Salbutamol 2P PRN

O/w- no chest pain

- no nausea
- no vomiting
- no diarrhea
- no abd pain
- no UTI Sx

 O/e-

conscious, very tachypneic,

accessory muscle, unable to speak in
complete sentences

BP-188/109
PR-155
RR-42
T-38.5

Generalised
Ronchi

Investigation
FBC

WBC
Hb
Hct
Plt

: 17.7
: 14.8
: 46
: 298

RP

Na : 136
K
: 4.6
Urea : 4.7
Creat: 100

ABG

pH
: 7.232
pCO2 : 60.0
pO2
: 95.5
HCO3 : 21.2
BE
: -4.0
ctCO2 : 26.5
O2 Sat : 95.9

Acute Severe Asthma !!!

Inability

to complete a sentences in one

breath
RR > 25
PR > 110
PEFR 33-50% of predicted normal or
patients best

Life Threatening Asthma !!

Silent

chest, cyanosis or feeble resp effort

Exhausted, altered conscious level
Bradycardia or hypotension or coma
PEFR < 33% of predicted or best
pO2 < 60
pCO2 > 32
Ph < 7.35

Lets Revised !!!

PR

>110 (155)
RR >25 (42)
Inability to
complete a
sentences in
one breath

pCO2 > 45 (60)

Ph < 7.35 (7.232)

Life Threatening
Asthma
Secondary to CAP

Management of Acute Severe Asthma

Assess

Asses severity of attack

Warn ICU if severe/life threatening attack

Neb Salbutamol
Immediate IV Hydrocortisone
treatment

Neb Salbutamol every 15 min

Add ipratropium 0.5mg in Neb
Life
threatening IV MgSO4 1.2-2g over 20 min

If not Improving :
Intubation
Refer ICU for
ventilatory
support

If Improving
within 15-30
minutes :
Neb Salbutamol
every 4 hours
Prednisolone for
5-7 day
Monitor SpO2

Management at ED :
IV

hydrocortisone 200mg stat

IV mgSO4 2.47g
CPAP trial with atrovent fail(then SPO 2
keep dropping)

Management at ED :
Proceed with RSI : anchored at 20cm, size 8
cm
IV fentanyl 100mcg
IV midazolam 3mg
IV scolene 100mg
IV midamorphine 3mg
Raindrop atrovent

Casualty Clerking :
ABG

ABG

pH
: 7.232
pCO2 : 60.0
pO2
: 95.5
HCO3 : 21.2
BE
: -4.0
ctCO2 : 26.5
O2 Sat : 95.9

pH
: 7.228
pCO2 : 50.4
pO2
: 315.4
HCO3 : 20.5
BE
: -7.3
ctCO2 : 22.1
O2 Sat : 99.6

Casualty Clerking :
Plan:

-Refer anaesth team for ventilation support

-start antibiotic IV Rochepin 2g stat 1g OD
& IV azithromycin 500mg OD
- Neb Salbutamol hourly & Neb Combivent
2 hourly

Anaesth Plan:
Admit

ICU
Cont midamorphine
IV Ranitidine
IV hydrocortisone
T neulin SR
KNBM
IVD 4 pint NS D5%/24 hour

27.6.2015 (day 2)
ABG

pH - 7.265
PCO2 - 43
PO2 -98.7
Cont

Abx
Cont Neb

30.6.15 (day 5)
Pt

was extubated at 6.30pm

Then given VMO2 60%
ABG

-pH 7.443/36.6/25.5/97.8
Completed
Cont

5 day IV azithromycin

Iv rochepine

3.7.15 (day 8)
Pt

was transferred to t4
Fever touch down
Change to NPO2 3L/min
Cultures show NG
Cont neb salbutamol & combivent 4 hourly
Cont

IV rocepine D8 (to complete 10 days)

Discharge

ICU care

Discharge

from t4 on 5.7.15 once completed rochpine D10