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Acute severe asthma — SCE Acute Medicine MCQ

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ModerateAcute Respiratory PresentationsAcute severe asthmaSCE Acute Medicine

A 31-year-old man with asthma is brought to the AMU with worsening breathlessness despite repeated salbutamol. He is unable to complete sentences, pulse is 128/min, respiratory rate 34/min and oxygen saturation is 92% on oxygen. Peak expiratory flow is 34% of his best and chest auscultation reveals widespread wheeze. Initial nebulised salbutamol and ipratropium have been given. What is the most appropriate next step in management?

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Correct answer: B — Give intravenous magnesium sulfate and seek senior critical care review

This is acute severe asthma with poor response to initial bronchodilator therapy, so IV magnesium sulfate with senior escalation is appropriate. Oral steroids are important but are insufficient as the next escalation after failure of nebulised bronchodilators in a high-risk presentation. CT pulmonary angiography would distract from the immediate airway and breathing problem. The key pearl is that a normal or rising PaCO2 in severe asthma is ominous, but treatment escalation should not wait for respiratory arrest.

Reference: BTS/NICE/SIGN Asthma pathway NG244