Exacerbation of Asthma

Published 03/08/2022

Exacerbation of Asthma




2 peripheral cannulae 






NIV machine & relevant interface 


Airway trolley 

Clinical Setting

I:       You are the ICU registrar and are called to resus to assess a patient 

S:      ED registrar reports brittle asthmatic requiring NIV – poorly tolerant 

B:      32 year old female with known asthma, hypoxic and wheezy 

A:     Commencing on BiPAP, ketamine infusion being prepared 

R:      Please review for HDU admission 

Potential Clinical Course

  • Initially A own, B Sp02 92% on FiO2 0.4, RR 32, diffuse wheeze C HR 115, BP 100/60 (falling), CRT >3sec, D GCS14/15 losing one on eyes 


  • ED reg leaves to attend another patient 
  • Reg makes own assessment and plans – interventions as requested 
  • ED reg returns with ABG – normocapneoic. Insists to commence NIV – starts at 14/8 
  • Leaves to review another patient 
  • Returns and enquires how the patient is doing – now more drowsy 
  • Decision to I+V: - ED reg comes up with drugs plan – 25mg suxamethonium, 2mg midazolam, no opiates. Reasons that “we want to be able to wake the patient up, if we can’t intubate them” 
  • Prepares for intubation – on giving the drugs, a nurse enters the room and informs the ED reg that the patient’s family have arrived. ED reg leaves. 
  • End-point of scenario is salvage of the situation, and intubation/ventilation. High airway pressures with slow to pick up EtCO2 – “if in doubt pull it out?”. Rationalises ventilation modality and settings. 


Information for Faculty

  • Initial settings: SpO2 92% on FiO2 0.4 
    • ETCO2 off 
    • RR 32 
    • Diffuse wheeze 
    • HR 115bpm SR 
    • BP 100/60 
    • Eyes closed but opens when patient spoken to 


  • Initial deterioration: SpO2 90% on FiO2 0.4 – NIV applied 
    • ETCO2 off 
    • RR 26 
    • Silent chest 
    • HR 123bpm SR 
    • BP 90/55 
    • Eyes closed. Still responding but confused verbally 


  • On induction of anaesthesia:  
    • SpO2 drops to 82% 
    • ETCO2 3.0kPa if in circuit 
    • RR 0 – depends on candidate manually ventilating patient 
    • HR 146bpm SR 
    • BP 76/34 


  • After intubation: SpO2 inc to low 90s 
    • Very rigid chest when using AMBU bag/test lung with clamp on 
    • RR depends on candidate 
    • HR 127bpm SR 
    • BP 86/45 


Faculty Roles

Bedside Nurse 1:  

  • You are an experienced ED Nurse 
  • You are concerned that the patient has been refusing the NIV, and constantly reassure the patient 
  • You want to help but are wary that the ED reg is conflicting with what the ICU reg is saying 


Bedside Nurse 2: 

  • You are a new starter 
  • You have basic nursing skills but no specific ICU/airway skills 
  • You have no idea what is going on, and seem pretty disinterested 
  • You take direction well 
  • You are the one who is constantly leaving to retrieve the things that are asked for - blood gases etc 
  • It is your role to drag the ED reg away immediately after induction of anaesthesia as “the patient’s family have arrived and are demanding to know what’s going on” 


ED reg: 

  • You are forthright and clear 
  • When the ICU reg questions what you’re doing, you tell them you’ve been doing this for a long time 
  • You don’t really want their help you just want them to review the patient as they need to go to HDU for NIV 
  • Dismiss any of their suggestions 
  • You dismiss any nursing concerns, nor do you listen to the patient who is claustrophobic and doesn’t want NIV 


ICU consultant: 

  • Arrive and offer help, take handover 


HiLLO: 10, 11