Case 06 · Respiratory
Acute severe asthma
A 24-year-old who stopped her preventer months ago has been wheezing all night in heavy smog, and her inhaler no longer works. She can only speak in words. Measure how sick she is, treat fast, spot the moment she starts to tire, and get the ventilator right if she needs one.
About this case
What you will practise
Learning objectives
- Classify acute asthma objectively with PEF, SpO₂, speech, respiratory rate, heart rate and conscious level, and keep reassessing.
- Give oxygen-driven salbutamol with ipratropium, and systemic steroids early.
- Recognise a poor response and give back-to-back nebulisers and IV magnesium.
- Recognise life-threatening and near-fatal features, including a silent chest and a “normal” or rising pCO₂, and involve ICU early.
- Ventilate an asthmatic safely: low rate, long expiration, and what to do about gas trapping.
- Plan admission, steroids, inhaler review, an action plan and follow-up.
Key decisions this case tests
- Is a quiet chest a better chest?
- The nurse asks to sedate her because she is panicking. Do you agree?
- When is a pCO₂ of 38 mmHg an emergency?
- When to add magnesium, and when to call ICU.
- The ventilator alarms and her BP falls after intubation. What now?
Reference basis
- British Thoracic Society / SIGN. British guideline on the management of asthma (SIGN 158, 2019): acute asthma in adults.
- Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2024 report: management of exacerbations.
Content version 1.0 · November 2026 · clinical review pending. See the Clinical content policy.
Before you start
The physiology is a simplified teaching model: the airway obstruction, fatigue and steroid effects are timed for learning, not prediction, and steroid onset is compressed. Doses follow the cited guidelines but have not yet been signed off by a clinician.
Visle is for education only and is not medical advice. Severe breathlessness that does not settle with a reliever inhaler is an emergency: seek urgent medical help.
Ready for another emergency?
Case 05 puts you at the bedside of a drug-induced anaphylaxis in a patient whose beta-blocker blunts her response to adrenaline.