Emily Salbutamol Assessment Of Asthma Exacerbations In Adults Oxygen Transport General Asthma Guidelines V Q Mismatch Difficult And Brittle Asthma Carbon Dioxide Transport B T S Treatment Guidelines Summary Basic Questions About Emily Airway Resistance Pharmacology Respiratory

4am. I’d sat down for the first time that night but once again my bleep was going off – accident and emergency. It was a young woman I’d met a few times before, Emily. Everyone in A&E knew her as she seemed to have pretty serious attacks of asthma every few months. ^{Difficult And Brittle Asthma}

With a deep sigh I went to see her. She looked like she was struggling for breath, but still managed a smile and a wave from behind the salbutamol nebuliser mist. She had a cannula in a vein in one hand and had just been given 100 microg of hydrocortisone intravenously.^{Airway Resistance ◦Salbutamol}

The nurse said her “sats weren’t picking up” on her finger, so she had the pulse oximeter on her ear. It was reading “91%” haemoglobin saturation. ^{Oxygen Transport}

Seeing her sats that low made my heart start thumping. Emily’s heart was racing too – 130bpm. She looked distressed and wasn’t able to say more than a couple of words without having to stop for breath. ^{Assessment Of Asthma Exacerbations In Adults}

I knew that with sats that low, the BTS guidelines indicate a blood gas analysis, so took an arterial sample from her radial artery to look at the gas tensions. When I saw the results of the ABG my heart sank:

I felt her oxygen levels really should be better than this, especially considering that the nebuliser was oxygen-driven at 6 l/min. A little panic started to settle in.^{V Q Mismatch}

I knew that my registrar was busy putting a central line into a patient on coronary care and that it was up to me to do whatever I could to improve Emily’s state.  These are the scary times as a junior doctor.  Emily was getting no better, and not responding to the care that had helped in the past when she had presented.

It was now 5.30am and I’d given her back-to-back salbutamol nebulisers, ipratropium nebulisers and even intravenous magnesium. That's everything that should help and the usual last resorts. I'd spent an hour an a half watching Emily's condition continuously decline, despite every intervention the guidelines suggest. She looked awful and now seemed a bit confused and drowsy. Her blood pressure was dropping to 80/40 and her breathing had slowed down to 10 breaths per minute. She was exhausted, hypoxaemic and possibly hypercapnic.  With trepidation, I repeated the blood gas, and my heart sank even further:^{Carbon Dioxide Transport}

Her CO₂ was now seriously elevated: Type II respiratory failure.  The nurse looking after her was frantic and I knew that I had to do something fast or she was going to die!^{Near Fatal Asthma}

I rang the intensive care unit and thankfully the registrar came straight down. Within a few minutes she was intubated and ventilated down in the A&E and shortly after that she was transferred to intensive care. I felt a sense of relief! Thankfully she did really well, and after two days on ICU it was possible to transfer her to the respiratory ward and a few days after that she went home. Quite a few changes were made to her medications and I'm hoping that I won't meet her in A and E again anytime soon! ^{B T S Treatment Guidelines Summary}