A 34-year-old man is admitted with a history of asthma, diabetes mellitus type 1 and a previous hospital admission with pneumonia. He presented with increased shortness of breath over the last 4 days and says his cough is worse than usual. The nurse is concerned because his oxygen saturations are 81% on air and his respiratory rate is 34 breaths/min.

You start to assess the patient using the ABCDE approach.

You think your patient his having an asthma attack.

What does your examination of his chest reveal?

Looking at the patient, he is tachypnoiec with signs of increased work of breathing and is not able to speak in full sentences. He has symmetrical chest movements and a central trachea. He has bilateral expiratory wheeze signifying bronchospasm.

His observations are - Heart Rate 109 beats/min, Blood Pressure 135/75 mmHg, Respiratory Rate 40 breaths/min, Oxygen (O2) saturations (SaO2) - 76%

Name 4 further management steps

  1. Sit the patient up and give oxygen
  2. Salbutamol (5 mg nebulised)
  3. Ipratropium bromide (500 mcg nebulised)
  4. Hydrocortisone (100 mg intravenously) or prednisolone (40 mg orally)

What oxygen delivery device would you have the patient on?

15 L/min via a reservoir mask. Nebulised bronchodilator therapy should be driven with oxygen.

After the above management steps that you have just carried out, the patient starts to improve. His respiratory rate is now 22 breaths/min and his wheeze is improving.

A few minutes later your patient becomes suddenly very short of breath and his O2 saturations drop to 70%. On examination there is reduced air entry and hyper resonance on the right side of his chest.

What could be the problem now?

Pneumothorax. There is a risk of pneumothorax in patients with asthma and a sudden deterioration should always prompt further examination. The examination findings of reduced air entry and hyper resonance are consistent with a pneumothorax. The trachea should be examined for deviation and a CXR requested to confirm the diagnosis.

His blood pressure is now 75/40 mmHg, RR 34 breaths/min, SaO2 65% and he is becoming drowsy.

What are your next steps?

There is evidence that this is developing into a tension pneumothorax with a resultant drop in the blood pressure. This is an immediate life threatening problem. Needle decompression with a large bore cannula 2nd intercostal space mid clavicular line is required.

After your correct management senior help arrives and a definitive management plan of the patient’s new condition is implemented.

One of the senior doctors now hands you the arterial blood gas sample results taken when you first saw the patient and asks you to interpret it.

2.9 kPa
7.30 kPa
25 mmol/L


How would you summarise this ABG?

Write down the features of a “life-threatening” asthma attack.