A 37-year-old lady is admitted to hospital with what the A&E doctors suspect is a SEVERE asthma attack. Which of the following signs or symptoms is consistent with that diagnosis? a. Silent chest, peak expiratory flow rate (PEFR) 33% of predicted

b. Acute exacerbations of asthma can be defined as severe or life-threatening. Criteria for diagnosis are as follows:

Severe attack

 • unable to complete sentences

• respiratory rate of greater than 25/minute

• heart rate greater than 110 beats per minute

• PEFR of less than 50% of predicted

Life-threatening

• cyanosis, very poor respiratory effort

• silent chest

• bradycardia and hypotension

Arterial blood sampling will show normal or high PCO2 and PO2 less than 8kPa.

In any case of asthma exacerbation a chest X-ray should be ordered to exclude a pneumothorax and to look for a concurrent pneumonia. The principles for management of exacerbations can be remembered by the mnemonic ‘O SHIT’;

O: Oxygen

S: Salbutamol

H: Hydrocortisone (or prednisolone)

I: Inhaled steroids

T: Theophylline (be aware of risks of toxicity – if not already on regular theophyllines will need a loading dose)

Magnesium is now used in acute asthma and the use of theophyllines is reducing. Check with your trust about local policy