Severe Asthma Exacerbation

This week’s case is written by Dr. Andrew Hall. He is an Assistant Professor in the Department of Emergency Medicine at Queen’s University where he is a Simulation-based Resuscitation Rounds Instructor and runs the Simulation-based OSCE Assessment Program for EM residents. He’s also one of the advisory board members here at EMSimCases.

Why it Matters

Acute asthma exacerbations are extremely common. Most asthmatics improve quickly after basic treatment with beta-agonists, anticholinergics, and steroids. This case highlights the management of those patients who don’t respond to the basics, including the following important points:

  • Severe asthma requires immediate, continuous treatment
  • Adjuncts to treatment such as magnesium sulfate, iv epinephrine, and bipap may be required
  • Ventilation in a severe asthmatic is extremely challenging due to air trapping and the need for prolonged expiratory time

Clinical Vignette

(vignette delivered by ER RN) A patient has been brought in by EMS and triaged to a Resuscitation Room in the Emergency Department with shortness of breath. He has had an upper respiratory tract infection with cough for 4 days. He’s now been having increasing SOB and chest tightness for 12 hours. He may have had a fever yesterday. EMS was called by a housemate who found him struggling to breathe at home. He is no longer responding to ventolin (using 4 puffs q30 min) and has rapidly worsened over the last hour. EMS reported vitals are HR 140, RR 41, O2Sat 85% on 100% O2 with face mask.

Case Summary

22 y.o. male is brought by EMS to the emergency department with increasing SOB and chest tightness x12 hours with rapid deterioration over the last hour resulting from a severe asthma exacerbation. He will require multiple pharmaceutical treatments, rapid sequence intubation and proper ventilation.

Download the case here: Asthma Exacerbation

CXR for the case found here:

Hyperinflation CXR

(CXR source:

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