Case history
Case history #1
A 5-year-old girl presents to the emergency department with a 2-day history of coryza and cough with intermittent low-grade fever. She developed an audible wheeze and respiratory distress that was initially responsive to salbutamol via a pressurised metered-dose inhaler and small-volume spacer. However, symptoms have recurred within 2 hours of salbutamol administration. The patient has had a number of episodes of wheeze and dyspnoea over a 2-year period; these were more common during the winter months. She required prednisolone on 2 occasions to treat severe wheeze. On examination she is in visible respiratory distress with a respiratory rate of 40 breaths/minute and has accompanying accessory muscle use. Her oxygen saturations are 92% in room air, and on auscultation of her chest there is widespread polyphonic wheeze and equal air entry.
Case history #2
An 11-year-old girl presents to the emergency department with a 12-hour history of a troublesome cough followed by wheezing and increasing breathlessness unresponsive to inhaled salbutamol. She has had troublesome asthma since the age of 18 months. Over the past few months, her asthma has been managed with fluticasone/salmeterol via a pressurised metered-dose inhaler and large-volume spacer, and an salbutamol inhaler, which is used as needed. She has been poorly compliant with her preventive medication, adhering only when symptomatic. On examination she is extremely distressed. She appears slightly cyanosed on air, and pulse oximetry shows an oxygen saturation of 84%. She has marked use of accessory muscles and is unable to speak in sentences but can say single words. She has marked pulsus paradoxus on palpation. On auscultation of the chest, there is widespread expiratory wheeze but equal air entry.
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