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Acute asthma exacerbation — UKMLA MCQ

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ModerateRespiratory MedicineAcute asthma exacerbationUKMLAMRCGP AKTPARAMRCEM SBAPSA

A 23-year-old man presents to his GP surgery with acute shortness of breath and wheeze at rest. His PEF is 180 L/min against a predicted value of 500 L/min. He can speak only in short phrases. His respiratory rate is 30/min, SpO2 is 93% on air and pulse is 120 beats/min. Ambulance transfer to hospital is being arranged. Which immediate treatment is most appropriate while awaiting transfer?

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Correct answer: D — Controlled oxygen, nebulised salbutamol plus ipratropium, and oral prednisolone 40–50 mg

This is acute severe asthma: PEF is 36% predicted, with inability to speak normally, RR 30/min and pulse 120 beats/min. Give controlled oxygen to maintain SpO2 94–98%, high-dose inhaled beta-2 agonist treatment—here nebulised salbutamol—with nebulised ipratropium, and early systemic corticosteroid treatment with prednisolone 40–50 mg while arranging urgent hospital transfer. Ipratropium alone does not provide adequate first-line bronchodilation. Prednisolone 20 mg is below the recommended adult dose and corticosteroid monotherapy would act too slowly. High-dose inhaled beclometasone does not replace acute bronchodilator and systemic steroid treatment. Intravenous aminophylline is not routine initial management and should only be considered in refractory cases under specialist hospital supervision.

Reference: Healthcare Improvement Scotland. Asthma pathway (BTS, NICE, SIGN) [SIGN 244], Treatment of acute asthma in adults and Management of acute asthma in adults in general practice. BTS/SIGN 2019 recommendations retained in the pathway reviewed 27 November 2024. https://www.rightdecisions.scot.nhs.uk/asthma-pathway-bts-nice-sign-sign-244/managing-acute-asthma/management-of-acute-asthma-in-adults/treatment-of-acute-asthma-in-adults/