How to manage a patient with chest tightness and difficulty passing air after treatment with salbutamol and ipratropium, and oxygen therapy?

Management After Initial Bronchodilator Treatment

You must reassess the patient 15-30 minutes after administering the nebulized bronchodilators to determine response and guide next steps. 1

Immediate Reassessment Required

Measure and document the following parameters now:

• Peak expiratory flow (PEF) - most critical objective measure 1
• Respiratory rate (severe if >25 breaths/min in adults) 1
• Heart rate (severe if >110 beats/min in adults) 1
• Ability to complete sentences (inability indicates severe asthma) 1
• Oxygen saturation - maintain at 94-98% (or >92% minimum) 2

Decision Algorithm Based on Response

If Patient is Improving (PEF >50% predicted/best)

Administer systemic corticosteroids immediately:

• Prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg 1
• Continue oxygen to maintain saturation 94-98% 2
• Step up usual inhaled treatment 1
• Arrange follow-up within 48 hours if PEF 50-75%, or within 24 hours if initially severe 1

If Patient is NOT Improving or Has Persistent Severe Features

Arrange immediate hospital admission if any of the following persist: 1

• Cannot complete sentences in one breath
• Pulse >110 beats/min
• Respiratory rate >25 breaths/min
• PEF <50% predicted or best
• Any life-threatening features (silent chest, cyanosis, exhaustion, confusion, bradycardia)

While arranging admission, immediately:

• Repeat nebulized ipratropium 0.5 mg 1
• Give prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg 1
• Continue high-flow oxygen 40-60% 1
• Consider subcutaneous terbutaline or intravenous aminophylline if life-threatening features present 1

Oxygen Management Adjustment

Your current 6 L/min may be insufficient for severe exacerbations:

• Increase to 40-60% oxygen (typically 10-15 L/min via reservoir mask) if patient has severe features or saturation <85% 1, 2
• Use oxygen to drive nebulizers at flow rate >6 L/min 2
• Target saturation 94-98% in most patients 2

Critical Pitfalls to Avoid

Underuse of corticosteroids is a major contributor to asthma deaths - give prednisolone/hydrocortisone to ANY patient with acute severe features, even if they appear to be improving 1. The British Thoracic Society emphasizes that delay can be fatal and doctors commonly fail to appreciate severity 1.

Do not discharge without objective improvement - response must be assessed before leaving the patient 1. Patients with afternoon/evening attacks, recent hospital admissions, or PEF <33% after treatment require lower threshold for admission 1.

Repeat nebulized bronchodilators more frequently if needed - can give every 15-30 minutes in non-responding patients 1.