Manage a child with acute severe asthma in the emergency department — OSCE

Candidate brief

You have this station to assess a 9-year-old with acute asthma, deliver the initial management, recognise and respond to deterioration, and outline safe disposition. Assess severity from the whole child, treat immediately and in the right order, and reassess after every step. [1] [2]

Key teaching and management objectives

Begin with a rapid severity assessment: he is in acute severe asthma — speaking only in short phrases, hypoxaemic at 89% on air, with marked work of breathing, tachypnoea and tachycardia. Sit him up, keep him calm, give oxygen titrated to keep SpO2 at or above 94%, and start continuous or back-to-back nebulised salbutamol with nebulised ipratropium 250 micrograms, because continuous salbutamol beats intermittent dosing and adding ipratropium reduces admissions in severe disease. Give a systemic corticosteroid early — oral prednisolone 1–2 mg/kg, or intravenous methylprednisolone or hydrocortisone if not tolerated — because its benefit takes hours to appear. Call for senior help and establish monitoring. [2] [4]

Reassess after the first treatments. If he is not responding — persisting hypoxaemia, ongoing marked work of breathing, or any life-threatening feature — escalate without delay. The first intravenous escalation is a single dose of intravenous magnesium sulfate; if he continues to fail, move to intravenous salbutamol and/or aminophylline in a monitored HDU or PICU setting with cardiac and electrolyte monitoring, and involve anaesthetics and PICU early. [3] [1]

Demonstrate that you can recognise deterioration: a quietening wheeze progressing to a silent chest, drowsiness or exhaustion, a feeble respiratory effort, or a rising or normalising PaCO2 in a tiring child are danger signs of impending respiratory failure, not improvement. Escalate to critical care and prepare for a controlled, high-risk intubation performed by the most experienced operator, ventilating slowly with permissive hypercapnia to avoid worsening air trapping. Exclude anaphylaxis if the onset was sudden after an exposure and give intramuscular adrenaline first if suspected. [1] [3]

Close with safe disposition and prevention. A child who settles, can space bronchodilator to several hours apart, saturates well on air and is comfortable can be discharged with a short steroid course; one who needed continuous or intravenous therapy or oxygen is admitted, and the severe or deteriorating child goes to HDU or PICU. Before discharge, check inhaler and spacer technique, ensure a preventer plan and a written asthma action plan are in place, address the trigger and adherence gap that led to the exacerbation, and arrange early follow-up — because this is when the next episode is prevented. [4] [1]