Acute severe asthma attack in a teenager
PLAB 2 & PRES 3 · respiratory / paediatrics · hard · 10 minutes
Candidate brief
You are an FY2 doctor in the emergency department resuscitation area. Chloe Bennett, 15, has been brought in by her mother after an asthma attack that began during a school PE lesson two hours ago. She has used her blue inhaler six times at home with little effect. She is sitting bolt upright, using her accessory muscles, and can only speak in single words. Observations: respiratory rate 32/min, SpO2 89% on air, pulse 128/min, BP 118/72 mmHg, temperature 36.7 °C. Peak flow is 180 L/min (her best is 400 L/min — 45% of best). Her mother is with her and is very anxious. Please assess the severity of the attack and manage it, escalating appropriately.
What examiners look for
Severity in asthma is graded by numbers and work, not by how dramatic the wheeze sounds: PEF against best, respiratory and heart rates, saturations, and the sentence test. Chloe fails every reassuring measure at the door — 45% of best and single words — so the grade "acute severe" should be spoken in the first minute, because it is what summons the right help. The quiet chest is the loudest alarm in respiratory medicine. Wheeze needs air movement; when a tiring teenager goes quiet, she is not settling, she is failing. Candidates who smile at the silence have the station's central trap exactly backwards. Treatment is a sequence with a clock: oxygen to a target, salbutamol nebulised and repeated, ipratropium added, steroids in the first hour. Each reassessment either buys improvement or buys an escalation — magnesium with senior input, critical care at the door — and the error is never the escalation, only the delay. Steroids are the forgotten early drug. Bronchodilators open airways for the hour; steroids change the next 24 hours and the admission itself. Prescribing them at minute 50, or leaving them "for the ward", is a systems failure candidates talk themselves into while being busy with nebulisers. Talk to the teenager in phrases she can answer and the mother in jobs she can do. A frightened 15-year-old breathes worse when a stranger fires questions; her mother, given a hand to hold and a role, becomes part of the monitoring team instead of a second patient. The attack ends; the asthma doesn't. A canister every five weeks, a preventer refused out of embarrassment, an action plan in a drawer, no copy at the school that ran her in cold air — the discharge work IS the prevention of the next resuscitation, and examiners reward the candidate who builds it without blaming a child for being fifteen.
Guideline references
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