Acute severe and life-threatening asthma — branching viva

Opening question

This 8-year-old can speak only in words, is saturating 88% on air with marked work of breathing and a widespread wheeze. How do you grade her severity, and what are your immediate management priorities? [1] [4]

Branch 1 — the child who is not responding

You have given oxygen, continuous salbutamol and ipratropium, and an early systemic steroid, but after the first hour she is still hypoxaemic with marked work of breathing. What is your first intravenous escalation, how do you give it, and what would you do if she continues to fail? [2] [3]

Branch 2 — deterioration to the danger signs

She becomes quieter, her wheeze softens to a nearly silent chest, she is drowsy, and a blood gas shows the PaCO2 has risen into the normal range. Why is this a deterioration and not an improvement, and what do you do now? [1] [3]

Branch 3 — the high-risk intubation

The decision is made to intubate. Why is intubation particularly hazardous in severe asthma, who should perform it, and what are the principles of ventilating this child? [1] [3]

Closing — disposition and prevention

Take the child who has recovered. How do you decide she is safe to discharge, and what must be in place before she leaves to prevent the next severe exacerbation? [4] [1]