Intro to EM - Asthma

Podcast – Intro to EM: The Patient with Asthma

Welcome to the St. Emlyn’s induction podcast, where we dive deep into the management of asthma in the emergency department. Asthma is a prevalent condition that emergency medical professionals encounter frequently. This blog post will provide a detailed step-by-step guide to managing patients presenting with asthma, including case presentation, assessment, treatment, and discharge planning. Whether you’re a seasoned practitioner or new to emergency medicine, this guide aims to enhance your understanding and improve patient outcomes.

Listening Time – 20:11


Imagine you’re in the resuscitation room when you’re alerted about an incoming patient. A 30-year-old female with a history of acute severe asthma is being brought in. She’s a smoker, consuming 20 cigarettes a day, and has had a history of hospital admissions, including an ICU stay a few years ago. As she is wheeled in, you notice she is short of breath with audible wheezing. This initial presentation provides critical information for immediate action.

First Steps: Rapid Assessment and Initial Management

Upon the patient’s arrival, it’s crucial to make a rapid assessment. Conducting an ABC (Airway, Breathing, Circulation) assessment is essential to confirm the diagnosis and gauge the severity of the asthma attack. Given the patient’s severe condition, it’s vital to start treatment immediately while continuing your assessment.

Immediate Actions

  1. High-Flow Oxygen: Administer high-flow oxygen to improve oxygen saturation levels.
  2. Nebulizers: Start with 5 mg of salbutamol and 500 mcg of ipratropium bromide. Don’t hesitate to administer another dose if needed.
  3. Listen to the Chest: A quick auscultation of the chest can help confirm the presence of wheezes and rule out other conditions like tension pneumothorax.

Understanding the Severity of Asthma

Assessing the severity of asthma is critical to guiding further treatment. The British Thoracic Society provides guidelines that classify asthma into mild, moderate, acute severe, and life-threatening categories.

Criteria for Severity

  1. Mild Asthma: Patients might experience mild dyspnea but can generally manage with minimal intervention.
  2. Moderate Asthma: Characterized by a peak flow more than 50% of predicted or best, moderate symptoms, and manageable at home with proper medication.
  3. Acute Severe Asthma: Marked by a peak flow below 50%, respiratory rate over 25, heart rate over 110, or an inability to complete sentences.
  4. Life-Threatening Asthma: Includes a peak flow less than 33%, low oxygen saturation below 92%, silent chest on auscultation, cyanosis, and signs of exhaustion.

Continuous Management: Treating Severe Asthma

In cases of severe or life-threatening asthma, continuous management and close monitoring are paramount.

Back-to-Back Nebulizers

Administering nebulizers continuously can help manage severe bronchoconstriction. Use salbutamol and ipratropium bromide back-to-back to provide relief.

Steroid Administration

Steroids play a crucial role in managing asthma by reducing inflammation. Administer oral steroids (1-2 mg/kg of prednisolone) or intravenous steroids if oral administration is not feasible.

Intravenous Bronchodilators

Consider intravenous bronchodilators like salbutamol if nebulized drugs are ineffective. Prepare IV salbutamol early to ensure it’s available when needed.

Magnesium Sulphate

Magnesium sulfate can be considered in severe cases. Although recent studies suggest it might not significantly impact, it is relatively safe and may benefit a small subgroup of patients.

Advanced Interventions: When Initial Treatments Fail

If the patient’s condition does not improve with initial treatments, advanced interventions may be necessary.

Critical Care Consultation

Engage with critical care colleagues early if the patient requires intensive care or ventilation. Ventilating an asthmatic patient is complex and requires experienced personnel.

Additional Therapies

  1. Ketamine Infusion: Ketamine can act as a bronchodilator and is used in managing severe asthma.
  2. CPAP: Continuous Positive Airway Pressure (CPAP) can be used in cases of severe air trapping and respiratory distress.

Importance of Senior Support

It’s vital for less experienced doctors to seek senior help when managing severe asthma cases. These patients require the most experienced care available.

Discharge Planning: Ensuring Safe Transition

For patients showing improvement, careful discharge planning is essential to prevent relapse and ensure ongoing management.

Criteria for Discharge

  1. Stability: Ensure the patient is stable for at least 6-8 hours after initial treatment.
  2. Follow-Up: Arrange follow-up with a general practitioner or asthma nurse within a few days.
  3. Medication Review: Ensure the patient has access to their inhalers and understands their use.
  4. Safety Netting: Advise the patient to return if symptoms worsen, even if they are already on their way home.

Safety Measures

Natalie May from St. Emlyn’s emphasizes the importance of advising patients to return if they have any concerns, even after leaving the hospital. Ensuring patients have their therapy and understand their treatment plan is crucial for safe discharge.

Conclusion: Recap and Key Takeaways

In summary, managing asthma in the emergency department requires a systematic approach:

  1. Rapid Assessment: Quickly assess the severity using ABC and confirm the diagnosis.
  2. Immediate Treatment: Administer high-flow oxygen and nebulizers without delay.
  3. Continuous Management: Use back-to-back nebulizers, steroids, and consider IV bronchodilators and magnesium sulphate.
  4. Advanced Interventions: Engage critical care and consider additional therapies like ketamine and CPAP.
  5. Discharge Planning: Ensure the patient is stable, arrange follow-up, review medications, and provide safety netting advice.

Asthma management in emergency settings is challenging but manageable with the right approach and timely interventions. Always prioritize the patient’s safety and seek senior support when needed.

Podcast Transcription

Where to listen

You can listen to our podcast in numerous ways, ensuring you never miss an episode no matter where you are or what device you’re using. For the traditionalists, Apple Podcasts and Google Podcasts offer easy access with seamless integration across all your Apple or Android devices. Spotify and Amazon Music are perfect for those who like to mix their tunes with their talks, providing a rich listening experience. If you prefer a more curated approach, platforms like Podchaser and TuneIn specialize in personalising content to your tastes. For those on the go, Overcast and Pocket Casts offer mobile-friendly features that enhance audio quality and manage playlists effortlessly. Lastly, don’t overlook YouTube for those who appreciate a visual element with their audio content. Choose any of these platforms and enjoy our podcast in a way that suits you best!

Cite this article as: Iain Beardsell, "Podcast – Intro to EM: The Patient with Asthma," in St.Emlyn's, May 6, 2015,

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