What is the management for a diabetic and hypertensive patient with acute shortness of breath, difficulty breathing, and wheezing on bilateral lung fields, currently on salbutamol (albuterol) inhaler and nebule, with vital signs showing tachycardia, hypertension, and normal oxygen saturation?

Management of Acute Severe Asthma Exacerbation

This patient is experiencing an acute severe asthma exacerbation requiring immediate aggressive treatment with high-dose oxygen, continuous nebulized bronchodilators, systemic corticosteroids, and consideration for hospital admission given the presence of multiple severe features despite recent treatment. 1

Immediate Assessment Priorities

Critical Features to Identify NOW

Life-threatening features requiring ICU consideration: 1, 2

• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia, hypotension, or arrhythmias
• Exhaustion, confusion, altered mental status, or coma
• SpO2 <92% despite supplemental oxygen
• PaCO2 >45 mmHg or rising (indicates respiratory failure)

Severe features present in this patient: 1

• Tachycardia (HR 124) and tachypnea (RR 25) - both exceed thresholds (>110 bpm, >25/min)
• Tripod positioning - indicates severe respiratory distress
• Inability to complete sentences in one breath (implied by "distress")
• Bilateral wheezing with increased work of breathing
• Recent treatment failure (symptoms within 1 hour despite salbutamol)

Essential Immediate Examinations

Measure peak expiratory flow (PEF) immediately - this is the single most important objective measure: 1

• PEF <50% predicted = acute severe asthma
• PEF <33% predicted = life-threatening asthma requiring ICU consideration

Obtain arterial blood gas if: 1, 2

• Any life-threatening features present
• SpO2 <92% on oxygen
• Patient not improving after initial treatment
• PEF <33% predicted

Check for pneumothorax - obtain chest X-ray urgently if: 1

• Sudden deterioration
• Unilateral decreased breath sounds
• Subcutaneous emphysema

Immediate Management Protocol

First-Line Treatment (Start ALL simultaneously)

Oxygen therapy - 40-60% immediately: 1, 3

• Target SpO2 >90% (>95% if pregnant or cardiac disease)
• CO2 retention is NOT aggravated by oxygen in asthma (unlike COPD)
• Use oxygen-driven nebulizers for all treatments

High-dose nebulized bronchodilators: 1, 3, 2

• Salbutamol 5 mg via oxygen-driven nebulizer immediately
• Repeat every 15-30 minutes for first hour if not improving
• If improving, continue every 4-6 hours

Systemic corticosteroids immediately (do NOT delay): 1, 2

• Prednisolone 30-60 mg PO OR
• IV hydrocortisone 200 mg (use IV if patient too distressed to swallow or vomiting)
• Clinical benefit requires 6-12 hours minimum, so early administration is critical

Second-Line Treatment (Add if no improvement after 15-30 minutes)

Ipratropium bromide: 1, 2

• Add ipratropium 0.5 mg to nebulizer with salbutamol
• Repeat every 4-6 hours until patient clearly improving
• Withdraw when PEF >75% predicted and diurnal variation <25%

IV aminophylline (consider if severe or deteriorating): 1, 2

• 250 mg IV over 20 minutes (loading dose)
• Only if patient not already on theophyllines
• Reserve for patients with very severe features or failing to respond to maximal nebulized therapy
• Monitor for arrhythmias and toxicity

Critical Monitoring Requirements

Continuous monitoring: 1, 2

• SpO2 continuously
• Heart rate and rhythm (ECG monitoring)
• Respiratory rate every 15 minutes
• Blood pressure every 30 minutes
• PEF before and 15-30 minutes after each nebulizer treatment

Repeat arterial blood gas within 2 hours if: 1, 2

• Initial PaO2 <60 mmHg (8 kPa)
• Initial PaCO2 normal or elevated
• Patient deteriorating clinically
• SpO2 cannot be maintained >92%

Special Considerations for Comorbidities

Diabetes Management

Monitor blood glucose closely: 4, 5

• Salbutamol can cause hyperglycemia through beta-2 receptor stimulation
• High-dose nebulized albuterol typically causes modest increases (mean 38 mg/dL)
• Systemic corticosteroids will significantly worsen hyperglycemia
• Check blood glucose every 2-4 hours during acute phase

Hypertension Management

Current BP 160/100 requires attention but NOT immediate antihypertensive treatment: 4

• Salbutamol causes tachycardia and can elevate blood pressure through beta-2 effects
• Hypertension typically improves as respiratory distress resolves
• NEVER use beta-blockers - they cause severe bronchospasm in asthma patients and block salbutamol effects 4
• Monitor BP every 30 minutes; treat only if sustained >180/110 after respiratory stabilization

Avoid these medications: 4

• Beta-blockers (including cardioselective) - contraindicated in acute asthma
• Non-potassium-sparing diuretics can worsen salbutamol-induced hypokalemia

Hospital Admission Criteria

Absolute indications for admission: 1, 2

• Any life-threatening features present
• PEF <33% predicted after initial treatment
• Any severe features persist after 1 hour of aggressive treatment
• Previous ICU admission for asthma
• Recent hospital admission or ED visit for asthma

Lower threshold for admission if: 1

• Attack occurred in afternoon/evening (worse prognosis)
• Recent nocturnal symptoms or previous severe attacks
• Poor social circumstances or inability to return quickly if worsens
• Poor compliance with medications
• Psychiatric illness or denial of severity

ICU Transfer Criteria

Transfer to ICU immediately if: 1, 2

• Deteriorating PEF despite treatment
• Worsening or persisting hypoxia (SpO2 <90% on high-flow oxygen)
• Hypercapnia (PaCO2 >45 mmHg) or rising PaCO2
• Exhaustion, confusion, drowsiness, or altered mental status
• Respiratory acidosis (pH <7.35)
• Respiratory arrest or requiring intubation

Discharge Criteria (When Patient Can Eventually Go Home)

Patient must meet ALL criteria: 1, 2

• PEF >75% predicted or personal best
• Diurnal PEF variability <25%
• No nocturnal symptoms
• Stable on discharge medications for 24-48 hours
• Correct inhaler technique verified and documented
• Written asthma action plan provided
• Follow-up arranged within 1 week with primary care
• Respiratory clinic appointment within 4 weeks

Discharge medications: 2

• Continue prednisolone 30-60 mg daily for 5-10 days total
• Initiate or optimize inhaled corticosteroid controller therapy
• Continue salbutamol as needed (but educate that frequent use indicates poor control)
• Provide peak flow meter for home monitoring

Common Pitfalls to Avoid

Do NOT delay systemic corticosteroids - they require 6-12 hours for clinical effect, so waiting to see if bronchodilators work alone wastes critical time. 1, 2

Do NOT restrict oxygen in asthma - unlike COPD, CO2 retention is not worsened by oxygen therapy in asthma; hypoxia kills faster than hypercapnia. 1

Do NOT use beta-blockers for hypertension management - even cardioselective agents can precipitate fatal bronchospasm in acute asthma. 4

Do NOT discharge too early - patients must be stable for 24-48 hours with PEF >75% predicted before discharge. 1, 2

Do NOT assume normal SpO2 means patient is stable - this patient has SpO2 97% but multiple severe features; PEF and clinical assessment are more important than oxygen saturation alone. 1