Before

Asthma

Asthma Pathophysiology

Overview of Respiratory Conditions

• Focus on asthma and chronic obstructive pulmonary disease (COPD)

• Presentation by Professor Anna Hutchinson, a critical care and respiratory nurse consultant

Asthma Overview

• Prevalence:

  • Affects approximately 12% of boys and 8% of girls in childhood

  • In adults over 25, prevalence shifts to 12-16% in women and 8-10% in men

• Pathophysiology:

  • Affects lower respiratory tract

  • Inflammation of lower airways and acute spasm of bronchial smooth muscles

  • Results in acute narrowing of airways

  • Symptoms include:

    • Wheezing

    • Shortness of breath

    • Coughing

    • Chest tightness

    • Decreased exercise tolerance

    • Fatigue

Risk Factors for Asthma

• Combination of genetic predisposition and environmental exposure

• Common Triggers:

  • Indoor/outdoor air pollution

  • Cigarette smoking

  • Household chemicals and cleaning products

  • Indoor pollutants (dust, molds, pet dander)

  • Bacterial and viral infections

  • Acute changes in weather, e.g., cold air, thunderstorms

  • Emotional changes (anger, fear)

  • Hormonal changes (pregnancy)

  • Physical exercise

  • Medications (e.g., aspirin, NSAIDs, and beta blockers) can worsen asthma

Thunderstorm Asthma

• A unique phenomenon occurring in specific Australian states

• Triggered by high pollen counts during hot, dry, and windy conditions

• 2016 Epidemic in Melbourne:

  • 3,365 hospital presentations and 10 deaths within 30 hours

  • Development of thunderstorm asthma forecasting system for early warnings

Severity of Asthma

• Ranges from mild intermittent symptoms to severe persistent inflammation

• Severe cases significantly affect quality of life, exercise capacity, and social participation

• Untreated episodes can be life-threatening

Treatment Strategies

• Focus on medications to decrease airway inflammation and treat bronchospasm

• Further details will be provided in the next video

• Reference to additional resources available through the Victorian Health Department.

Asthma Management - Treatment

Pathophysiology of Asthma

• Two key mechanisms drive the condition:

  • Inflammation of the Upper Respiratory Tract:

    • Inflammation of bronchial walls leads to acute narrowing of airways.

    • Chronic untreated inflammation can cause scarring and decrease lung function.

  • Acute Bronchospasm:

    • Caused by smooth muscle contraction in the bronchial tree.

Treatment Goals

Goals of asthma management:

• • Prevent and Control asthma symptoms

• • Maintain lung function and activity

• • Prevent morbidity and mortality

Patient education focuses on:

• • Avoidance of triggers

• • Pharmacotherapy

• • Self-management

Asthma action plans (& regular review):

• written document

• helps people with asthma to detect early warning signs/symptoms of an exacerbation

• provides instructions on how to manage exacerbations

The Asthma action plan should include three parts:

1. Maintenance therapy (when well)

2. Early exacerbation management (when not well)

3. Crisis management (If symptoms worsen - Danger Signs)

Types of Medications

Bronchodilators (Relievers)

• Medications for rapid relief of asthma symptoms.

• Can be used before exercise to prevent exercise-induced bronchoconstriction.

• Mechanism of action: relax bronchial smooth muscle (short-acting beta-agonists (SABAs)

• Main groups:

  • Beta-2 Agonists:

    • Main medications include:

      • Salbutamol (Ventolin)

        • Onset time: 2-5 minutes.

        • Duration of action: 4-6 hours.

        • Commonly used for acute asthma attacks in community settings.

      • Terbutaline (Bricilin).

• Types:

  • Short-acting Beta-2 Agonists:

    • For immediate relief of sudden breathlessness.

  • Long-acting Beta-2 Agonists:

    • Maintains action for 12-24 hours, daily dosage for asthma control.

    • Common examples include Salmeterol and Formoterol.

Preventers

• Aim to control asthma symptoms and prevent attacks.

• Reduce inflammation, redness, and swelling in airways:

  • Less sensitivity and lower risk of acute bronchospasm.

• Typically delivered as inhalers containing low dosages of corticosteroids routinely (daily)

Mainstay of treatment to address the root causes of asthma symptoms.

"Symptom controller" medications:

Aim: provide long-acting bronchodilation (up to 12 hours)

Mechanism of Action: relax bronchial smooth muscles (long-acting beta- agonists (LABAs))

Administered: once or twice daily

Examples: salmeterol, formoterol (both Beta2-agonists)

Combination Therapies

• Used in Australia for moderate to severe asthma treatment.

• Combines long-acting bronchodilators with corticosteroids in a single inhaler.

• Administered: once or twice daily

• Benefits include:

  • Long-acting reliever to decrease breakthrough symptoms.

  • Corticosteroid to reduce inflammation in the airways.

• Regular use is effective for:

  • Relieving symptoms.

  • Stabilizing asthma.

  • Decreasing the risk of exacerbations.

  • Improving patient quality of life.

The Nurses Role In Asthma Management

Chapter 1: Introduction to Asthma Management

• Overview of Nurses' Roles in Asthma Management

  • Nurses participate in multidisciplinary teams in primary care settings.

  • Roles include assessing patients and offering asthma education to improve control.

• Diagnosis of Asthma

  • Involves history, physical examination, ruling out other diagnoses, and spirometry to document airflow limitation.

  • Identification of asthma triggers is key (e.g., cigarette smoke, allergies, viral infections).

• Assessing Asthma Control

  • Many Australians live with poorly controlled asthma; frequent reliever use (e.g., Ventolin) is often mistaken for normal.

  • Nurses should engage patients to clarify asthma symptom control and prevention of exacerbations.

  • Use an evidence-based checklist for assessing control:

    • Do you wake at night with symptoms?

    • Do you have symptoms in the morning?

    • How soon do you need your reliever medication after waking?

    • How often do you need your reliever during the day?

    • Are your daily activities or exercise restricted by asthma?

    • Days off work or school due to asthma in the past couple of weeks?

Chapter 2: Written Asthma Action Plan

• Importance of Asthma Action Plans

  • Action plans should outline key steps during flare-ups, emergency contacts, and therapy.

  • Emphasize the importance of seeing healthcare professionals if symptoms persist.

• Proper Inhaler Use

  • Correct inhaler technique is crucial; many patients lack proper instruction.

  • Nurses should observe patients using their inhalers and correct misconceptions.

  • Resources available for demonstrations of proper inhaler use.

• Reviewing the Asthma Action Plan

  • Nurses should clarify the action plan with patients and families to ensure understanding during emergencies.

  • Role in community settings: administer medications per action plans and assess treatment responses.

Chapter 3: Signs of Deteriorating Asthma Control

• Recognizing Asthma Attacks

  • Typical signs: increased wheezing, cough, sudden chest tightness, and shortness of breath.

  • Gradual worsening of symptoms indicated by increased nighttime awakenings or frequent reliever use.

• Asthma Emergencies

  • Define an asthma emergency: sudden severe symptoms, difficulty speaking, or cyanosis (blue lips/fingers).

  • Immediate action: call an ambulance if relief is not achieved with the inhaler.

• Asthma First Aid Steps

  1. Sit the person upright and keep them calm.

  2. Administer four puffs of reliever medication (use a spacer if available).

  3. Wait four minutes and monitor the individual closely.

  4. If still not improving, call an ambulance and repeat salbutamol dosages (four puffs every four minutes).

Chapter 4: Conclusion

• Continuous Monitoring

  • After four minutes, if the person is responding, reassure them while monitoring until normal breathing resumes.

  • If improvement occurs, follow up with a healthcare provider for check-up.

• Asthma First Aid Plans for Different Ages

  • Review specific first aid plans for adults and children to account for differences in administration methods (e.g., spacer with or without a mask).

• Nurses' Crucial Role in Acute Care

  • Nurses support emergency treatment, assess responses, and provide respiratory care in acute settings (ED, medical wards, ICU).

  • Further details on managing acute asthma exacerbations will follow.

Chronic Obstructive Pulmonary Disease

Overview of COPD Pathology

• Chronic Obstructive Pulmonary Disease (COPD):

  • A chronic inflammatory disease that leads to obstructive airflow from the lungs.

  • Symptoms include:

    • Breathing difficulties

    • Chronic cough

    • Increased mucus production

    • Increased wheezing

  • Typically results from long-term exposure to irritating gases or particulate matter, most often from cigarette smoke.

  • Increased risk of developing:

    • Heart disease

    • Lung cancer

    • Other various conditions.

Underlying Conditions

• Emphysema:

  • Characterized by the progressive destruction of alveoli.

  • Decreases the area available for gas exchange in the lungs, leading to:

    • Progressive shortness of breath

    • Decreased exercise tolerance.

• Chronic Bronchitis:

  • Refers to chronic inflammation of the bronchial tubes' lining.

  • Symptoms include:

    • Daily cough

    • Daily mucus production.

  • Increased risk of:

    • Lower respiratory tract infections

    • Pneumonia.

  • Higher likelihood of requiring frequent hospitalizations for managing exacerbations.

Risk Factors and Exposures

• Onset of COPD:

  • Gradual development over time, often due to a combination of risk factors.

  • Common exposures that contribute to COPD include:

    • Tobacco smoke exposure

    • Occupational exposures

    • Indoor air pollution

    • Early life factors such as:

      • Poor growth in utero

      • Prematurity

      • Undertreated childhood asthma.

  • Alpha-one antitrypsin disorder: Rare genetic condition that leads to early onset and rapid progression of COPD.

Prevalence of COPD

• Global Statistics:

  • In 2019, COPD was the third leading cause of death worldwide.

  • Almost 90% of COPD deaths in individuals aged 70 and above occur in low and middle-income countries.

• COPD in Australia:

  • Affects both men and women.

  • Approximately 1 in 13 Australians aged 40 and over have some form of COPD.

  • About half of these individuals are unaware they have the condition.

  • Higher prevalence in Indigenous Australians, who are 2.5 times more likely to have COPD than non-Indigenous Australians.

• To improve patient outcomes, the following are essential:

  • Early diagnosis and treatment

  • Risk factor reduction

  • Ongoing support to slow disease progression and reduce exacerbation risks.

Diagnosis usually based on:

• • History of smoking or exposure to other noxious agents

• • FEV1/FVC % (forced expiratory ratio (FER) of ≤70%.

  GOLD Stage	FEV₁ (% of predicted value)	Symptoms & Severity

  Mild (Stage 1)

  ≥80%

  - May have chronic cough and sputum production. - Minimal impact on daily life. - Often undiagnosed at this stage.

  Moderate (Stage 2)

  50-79%

  - Worsening breathlessness on exertion. - Increased cough, sputum production, wheezing. - May require bronchodilator therapy.

  Severe (Stage 3)

  30-49%

  - Significant limitation in daily activities. - Frequent exacerbations requiring hospitalization. - Increased risk of respiratory failure.

  Very Severe (Stage 4)

  <30% (or <50% with chronic respiratory failure)

  - Extreme breathlessness (even at rest). - Recurrent exacerbations affecting quality of life. - May require long-term oxygen therapy (LTOT) or mechanical ventilation.

• • Other Pulmonary function tests (used to measure lung volumes

• and gas diffusion)

• • Chest x-ray

• • Blood gas analysis

• • Physical examination

COPD Management

Understanding COPD

• Chronic Obstructive Pulmonary Disease (COPD) causes irreversible lung damage.

• Early treatment is crucial to enhance quality of life and manage symptoms effectively.

• Strategies can be employed to slow progression and minimize flare-ups.

Steps to Improve Quality of Life

• Individuals can adopt various approaches for better health and energy, including:

  • Emotional Self-Care: Focusing on mental and emotional well-being.

  • Regular Exercise: Essential to prevent muscle weakness and loss of fitness.

  • Smoking Cessation: Quitting smoking is paramount; it is the most significant lifestyle change one can make.

Importance of Exercise

• Everyday Activities: Breathlessness during tasks like walking or washing can deter exercise.

• Research Findings: Regular exercise helps:

  • Maintain fitness

  • Improve overall well-being

  • Mitigate symptoms like breathlessness

• Pulmonary Rehabilitation:

  • Specifically designed for individuals with lung conditions.

  • Programs led by trained specialists (physiotherapists, exercise physiologists).

  • Tailored to individual fitness levels, emphasizing adaptability rather than traditional exercises.

Benefits of Pulmonary Rehabilitation

• Facilitates social interaction and provides a supportive environment.

• Improves both physical fitness and mental health.

• Teaches essential techniques:

  • Breathing Techniques: Helps to manage breathlessness.

  • Sputum Clearance Techniques: Useful for home management.

• Post-completion, it is critical to remain active and continue exercise for optimal lung health.

Continuing Support

• Lungs in Action Programs:

  • Offered across Australia, focuses on continued exercise with peers.

  • Provides a supportive network for those with similar lung conditions.

Emotional Health Considerations

• Recognizing that individuals experience COPD differently.

• Emotional health directly correlates with symptom severity, affecting social interactions and activity levels.

• Importance of maintaining social connections, even during tough days.

• Support Groups: Patients are encouraged to seek support from groups or health professionals if feeling overwhelmed.

Additional Health Guidelines

• Dietary Approach: Eating a healthy, nutritious diet.

• Rest and Sleep: Prioritize sufficient rest and quality sleep.

• Vaccinations: Keep vaccinations up-to-date (annual flu shot and pneumonia vaccination) to prevent additional health complications.

Reading Chest X-ray

X-rays are a common diagnostic test used for various conditions and to confirm the position of medical devices such as peripherally inserted central catheters (PICC), intercostal catheters (ICC) and nasogastric tubes.

Interpreting a chest x-ray is an extremely advanced skill however, as a nurse, it is important that you have the ability to identify the normal anatomical structures as well as perform a basic interpretation.

Understanding X-Rays

• X-rays are high-energy photons that penetrate body tissues, allowing visualization of internal structures.

• They behave similarly to visible light, having reduced penetration in denser materials.

• Conventional X-rays display white bones on a black background, resembling photographic negatives:

  • Dark areas (e.g., lungs) represent regions where more photons penetrate.

  • Bright white areas show dense bones that block photons.

Importance of a Systematic Approach

• Especially crucial for less experienced clinicians.

  • Reduces chance of missing important findings.

• All aspects of interpretation must be included.

• Sequence of examination should be logical and easy to remember.

• No single best system, but all should start with assessing film quality.

Checklist for Analyzing Chest X-Rays (A to G)

A: Assessment

• Begin with patient and exam data verification to avoid errors and ensure the correct study is being examined.

• Assess image quality:

  • Check for proper patient rotation by ensuring medial ends of spinous processes are equidistant from vertebral body borders.

  • Evaluate inspiration quality; the film should show at least the 10th or 11th ribs for full lung expansion.

  • Ensure exposure is adequate; adjust brightness to visualize fine lung markings clearly.

• Check for air in unintended locations (e.g., pneumothorax, pneumomediastinum). This is crucial for diagnosing surgical emergencies relative to air presence.

B: Bones

• Inspect both clavicles and all 12 pairs of ribs for:

  • Fractures

  • Deformities

  • Missing bones

• Examine body wall and soft tissues for swelling, masses, or irregularities; often overlooked.

C: Cardiac Silhouette and Size

• Assess the cardiac silhouette:

  • Features include the right atrium, left ventricle, and atrial appendage.

  • Orientation: Right atrium appears on the left side of the X-ray; left ventricle is on the right.

• Normal heart size should be less than 50% of the rib cage's greatest diameter; larger sizes may indicate pathology.

D: Diaphragms

• Diaphragms should be symmetric, with appropriate contour.

• In lateral views:

  • Estimate that a normal hemidiaphragm is 1.5 centimeters above the line connecting costophrenic and sternophrenic angles.

E: Equipment and Effusions

• Note the placement of lines, tubes, and wires associated with life support:

  • Endotracheal tubes should be centered in the trachea, at least 2 cm from the tracheal bifurcation.

  • Nasogastric tubes should be positioned within the stomach.

• Check for pleural effusion:

  • Fluid at costophrenic angles indicates blunting, affecting diagnostic interpretation.

F: Lung Fields

• Lung fields should appear symmetric with the absence of:

  • Haziness

  • White dots or blotches

• Use frontal and lateral X-rays to localize abnormalities:

  • Example: A nodular mass in the left lung's anterior segment can often be confirmed with CT scans.

G: Great Vessels

• Evaluate positioning and size of the great vessels:

  • Key structures: superior and inferior vena cava, ascending aorta, aortic arch, pulmonary artery, descending aorta.

• Orientation: Aortic arch should be positioned highest on the left side; other heart structures should be correctly aligned.

• Deviations may indicate underlying congenital issues or disease.

Recap of ABCDEFG Checkpoints

1. A: Assessment of data, quality, and identifying air abnormalities.

2. B: Bones in the body wall condition.

3. C: Cardiac silhouette measurement and size assessment.

4. D: Diaphragm evaluation for symmetry and flatness.

5. E: Check equipment placement and effusions.

6. F: Analysis of lung fields for symmetry and abnormalities.

7. G: Assessment of the great vessels' position and size.

• Focus of the video: systematic approach and normal chest X-ray anatomy.

• Learning objectives:

  • Familiarity with systematic approach for interpreting chest X-rays.

  • Understanding the correlation between anatomy and normal shadows on an X-ray.

ABCDEF System for Chest X-ray Interpretation

• Informally referred to in teaching as the ABCDEF system.

• Commonly used in the US, though not perfect.

• Breakdown of the system:

  • A: Airways - trachea in midline, right & left main bronchus.

  • B: Bones and Soft Tissue - assessment of visible bones.

  • C: Cardiac Silhouette and Mediastinum - various structures of the heart.

  • D: Diaphragm - includes gastric air bubble.

  • E: Effusions - assessment of the pleura.

  • F: Fields - examination of the lung fields.

• Additional consideration: assessing lines, tubes, devices, and prior surgeries.

• Lungs evaluated near the end to avoid distraction from significant abnormalities.

Airway Structures (A)

• Key anatomical structures visible on normal X-ray:

  • Trachea - located midline.

  • Right Main Bronchus - more vertical angle.

  • Left Main Bronchus - more horizontal angle.

• Implications:

  • Increased likelihood of foreign body aspiration into right lung.

  • Risk of endotracheal tube misplacement into right bronchus.

Bones and Soft Tissue (B)

• Identifiable bones on PA/lateral X-ray:

  • Ribs: posterior and anterior components.

  • Clavicles: right and left visible.

  • Sternum: may be obscured on lateral view.

  • Vertebral Bodies: usually visible on PA when quality is adequate.

Cardiac Silhouette and Mediastinum (C)

• Components to evaluate:

  • Shapes and sizes forming the cardiac silhouette.

  • Notable structures include the aortopulmonary window (location for recurrent laryngeal nerve and lymph nodes).

• Visualization techniques:

  • Use drawings for anatomy understanding.

Diaphragm and Pleura (D)

• Diaphragm characteristics:

  • Right hemidiaphragm generally higher due to liver.

  • Curvature represents 3D structure; assess both views.

• Pleura:

  • Surrounds lungs, usually invisible due to thinness.

• Costophrenic angles:

  • Right and left angles assess pleural spaces.

  • Posterior costophrenic angle visible on lateral.

• Gastric air bubble under left hemidiaphragm indicates stomach position.

Lung Fields and Fissures (F)

• Structures to examine in lungs:

  • Fissures:

    • One horizontal fissure visible on right, not usually visible in left lung.

    • Two oblique fissures on right, and one on left.

  • Lobes:

    • Right lung: divided into three lobes (upper, middle, lower).

    • Left lung: divided into two lobes (upper, lower).

• Fissure visibility aids in localization of lung abnormalities.

Passive Smoking & Its Impact on Asthma and COPD

Passive smoking (also known as secondhand smoke) occurs when a person inhales smoke from burning tobacco products or exhaled smoke from a smoker. It contains harmful chemicals like carbon monoxide, nicotine, formaldehyde, and benzene, which can damage lung tissue and trigger respiratory conditions.

Here’s how passive smoking affects asthma and COPD:

Impact of Passive Smoking on Asthma

1. Trigger for Asthma Attacks – Secondhand smoke is a common asthma trigger, leading to bronchoconstriction, inflammation, and excess mucus production.

2. Increased Severity & Frequency of Attacks – Children exposed to secondhand smoke have more frequent and severe asthma attacks than those in smoke-free environments.

3. Higher Risk of Developing Asthma – Long-term exposure to passive smoke increases the risk of developing asthma, especially in children.

4. Reduced Response to Treatment – Asthma patients exposed to secondhand smoke often respond poorly to medications, such as inhaled corticosteroids.

💡 Key Point: Passive smoking does not cause asthma directly, but it significantly worsens symptoms, increases attacks, and reduces treatment effectiveness.

Impact of Passive Smoking on COPD

1. Increased Risk of Developing COPD – Long-term exposure to secondhand smoke can lead to chronic bronchitis, airway inflammation, and lung damage, increasing the risk of COPD later in life.

2. Accelerated Lung Function Decline – Even in non-smokers, exposure to secondhand smoke can cause irreversible lung damage, leading to progressive airway obstruction.

3. More Frequent COPD Exacerbations – Passive smoking worsens COPD symptoms, leading to more frequent flare-ups, hospitalizations, and faster disease progression.

4. Increased Mortality Risk – Studies suggest that long-term secondhand smoke exposure raises the risk of premature death in COPD patients.

💡 Key Point: Passive smoking is a major risk factor for COPD, contributing to its development, worsening symptoms, and faster disease progression.

Updated Table Including Passive Smoking:

Final Thoughts

• Asthma patients exposed to secondhand smoke experience more severe attacks and reduced treatment effectiveness.

• COPD patients exposed to secondhand smoke suffer faster lung decline, more hospitalizations, and increased mortality risk.

• Avoiding passive smoking is critical for managing both conditions and preventing long-term lung damage.

Let me know if you need any further additions! 😊

Asthma vs COPD

Case Study

1. First Nursing Action & Initial Treatment/Management for Simon

• Rapid Assessment (ABCDE Approach)

  • Airway: Ensure the airway is open and not obstructed.

  • Breathing: Assess respiratory rate, oxygen saturation (SpO₂), and auscultate lung sounds for wheezing or silent chest (a dangerous sign of severe obstruction).

  • Circulation: Monitor heart rate and blood pressure (tachycardia may indicate hypoxia or medication side effects).

  • Disability: Assess consciousness level (severe hypoxia can lead to confusion or agitation).

  • Exposure: Identify any environmental triggers (e.g., cold air, allergens).

• Administer Oxygen Therapy (if required)

  • If oxygen saturation <92%, administer high-flow oxygen (via non-rebreather mask at 6-8 L/min) to prevent hypoxia.

• Positioning

  • Sit Simon in an upright position to ease breathing and lung expansion.

• Monitor for Life-Threatening Signs

  • Silent chest (no wheezing, no air entry)

  • Severe fatigue or confusion (signs of respiratory failure)

  • Cyanosis (blue lips or fingers)

  • Respiratory rate >25 or <8 breaths per minute

  • Unable to speak in full sentences

If any of these signs are present, urgent escalation to critical care is required.

2. Medications Simon is Most Likely to Receive Initially & Delivery Method

• 1st Line: Short-Acting Beta-2 Agonist (SABA) – Salbutamol (Ventolin)

  • How is it delivered?

    • Nebulizer (preferred in severe asthma): 5mg salbutamol nebulized with oxygen, repeated every 20 minutes as needed.

    • Metered-Dose Inhaler (MDI) with Spacer: 4-10 puffs, repeated every 20 minutes for 1 hour.

  • Purpose: Quickly relaxes airway muscles, relieving bronchoconstriction.

• 2nd Line: Anticholinergic – Ipratropium Bromide (Atrovent)

  • How is it delivered?

    • Via nebulizer (500 mcg every 20-30 minutes for up to 3 doses).

  • Purpose: Provides additional bronchodilation, especially in severe cases.

• 3rd Line: Systemic Corticosteroids – Prednisolone or IV Hydrocortisone

  • How is it delivered?

    • Oral Prednisolone: 40-50 mg once daily for 5 days.

    • IV Hydrocortisone (if unable to take oral medication): 100mg every 6 hours.

  • Purpose: Reduces airway inflammation and prevents further exacerbation.

• If No Improvement:

  • Consider IV Magnesium Sulfate (1.2-2g over 20 minutes) for severe cases or IV Prednisolone

  • Epinephrine (IM Adrenaline) if there is suspicion of anaphylaxis or if the patient is not responding to usual treatment.

3. Evaluating Treatment Effectiveness & When to Escalate Care

• Monitor Improvement:

  • Signs of Recovery:

    • Reduced respiratory rate

    • Improved oxygen saturation (>95%)

    • Reduced wheezing, ability to speak in full sentences

    • Decreased use of accessory muscles (less chest retraction)

    • Peak expiratory flow rate (PEFR) improving toward baseline

• Signs Treatment Is Not Working (Requires Escalation):

  • Persistent severe breathlessness despite treatment

  • Deteriorating SpO₂ (<90%) even with oxygen support

  • Silent chest (no wheezing, no air movement)

  • Exhaustion, confusion, or drowsiness (impending respiratory failure)

  • Blood gas abnormalities (respiratory acidosis, CO₂ retention)

🚨 If Simon Deteriorates Further:

• Escalate to ICU for ventilation support (Non-Invasive Ventilation or Intubation)

• Consider ICU referral if continuous nebulization, IV therapy, and oxygen therapy do not stabilize the patient.

Conclusion

• Immediate interventions: Oxygen, bronchodilators (salbutamol + ipratropium), and corticosteroids.

• Delivery method: Nebulizer for severe cases, inhaler/spacer if moderate.

• Monitor for response: If persistent severe symptoms, consider IV therapy or ICU escalation.