Lecture notes

• Asthma


  Reversible, chronic episodic condition with shortness of breath, common ED presentation
• History to assess in asthma

  • Onset of symptoms
  • Previous ICU admission
  • Visits to ED in the last month
  • Medications used at home
  • Smoking
  • History of "brittle" asthma
• Asthma severity categories


  • Mild
  • Moderate
  • Severe
  • Life threatening
• Life threatening asthma


  • Exhaustion
  • Confusion/Coma
  • Cyanosis
  • Silent Chest
  • Inability to speak
  • Poor respiratory Effort
  • Arrhythmia/Bradycardia
  • Hypotension
  • FEV1/PEFR inappropriate
  • SpO2<90% despite supplemental O2
• Severe asthma


  • Laboured Respiration
  • Sweating, Restless
  • Tachycardia, HR>120
  • Tachypnoea RR> 25/min
  • Speaking in words(max 3 at a time)
  • FEV1/PEFR unable or <40% predicted
  • SpO2 <90% on air
  • PEFR <200L/min
• Moderate asthma


  • SOB at rest
  • Able to speak short sentences
  • Chest tightness
  • Wheeze
  • Partial or short term relief with usual therapy
  • Nocturnal Symptoms
  • FEV1/PEFR 40% - 60% predicted
  • PEFR 200 – 300l/min
• Mild asthma


  • Exertional symptoms
  • Able to speak normally
  • Good Response to Usual Treatment
  • FEV1/PEFR >60% predicted
• Asthma management


  1. Triage to appropriate area

  2. Beta agonist nebulized (salbutamol) with O2

  3. Anticholinergic nebulized (atrovent)

  4. Corticosteroid

  5. Reassess continually
• Escalation of asthma treatment

  1. IV MgSO4 2.47g over 20 mins

  2. IV fluid (NS)

  3. Continuous nebs

  4. Adrenaline

  5. Consider IV aminophylline/ adrenaline

  6. Prepare airway equipment for intubation
• Criteria for asthma admission


  • Patient factors
  • Illness factors
  • Social factors
• Asthma discharge plan


  1. Give Medications (spacer, MDI, preventer)

  2. Patient Education
• Acute Pulmonary Edema


  Common presentation associated with bad outcome, usually fluid misdistribution rather than overload, aim of management is to maintain oxygenation and cardiac output
• Acute Pulmonary Edema presentation


  • Acute dyspnea
  • Diaphoresis
  • Hypoxia
  • May have preceding chest pain
  • History of IHD, HTN
• Acute Pulmonary Edema clinical features


  • Hypoxia
  • Air hunger
  • Cough with pink frothy sputum
  • Noisy breathing with crackles
  • Mostly hyper or normo-tensive
  • Hypotension= cardiogenic shock
  • Raised JVP
• Management of Acute Pulmonary Edema in normo/hypertensive patients


  1. Nitrates (pre/after load reduction)

  2. Oxygen

  3. Aspirin

  4. Morphine if pain

  5. NIV with CPAP (oxygenation and preload and afterload reduction)
• Management of Acute Pulmonary Edema in hypotensive patients


  1. Need both ventilator and hemodynamic support

  2. Small fluid boluses and Inotropic support

  3. Seek and treat reversible causes