Scenario — Acute asthma exacerbation in elderly female

foundation Respiratory · Elderly · 75yr · female

Patient Information

Dispatch	You are called to a 75YO female at the FAP who is having difficulty breathing. (Margaret Dunne, DOB 14/03/1950)
Patient	Margaret Dunne — 75yr (60kg)
Incident History	Pt states she has had asthma for many years and her breathing has become progressively worse over the last 20 minutes. She attended the Perth Royal Show and forgot her puffer at home.
Emergency Contact	Robert Dunne (Husband) — 0412 447 183

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil obstruction. Nil stridor.
Breathing	Laboured. Audible wheeze bilaterally. Unable to speak in full sentences. Accessory muscle use noted. RR 28/min. SpO2 90% on room air.
Circulation	Radial pulse present, regular, slightly elevated. Skin warm and dry. Nil cyanosis at this stage.
Disability	GCS 15 (E4V5M6). Alert and orientated to time, place and person. Anxious.
Exposure	No rashes, urticaria or visible injuries. No MedicAlert bracelet noted.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	90% (RA)	Severe	28	112	138/88	<2s	15	4 4 ++	37.1	–	3
10 mins	95% (O2 simple mask 6L/min)	Mild	20	98	134/84	<2s	15	4 4 ++	37.1	–	1

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a severe acute asthma exacerbation precipitated by allergen/irritant exposure at a show environment, complicated by absence of her personal reliever inhaler.

Facilitator Triggers — if trainees miss a critical step

! (If oxygen is not applied within 3 minutes of arrival, SpO2 drops to 88% and patient becomes more distressed, unable to complete any words.)
! (If salbutamol MDI via spacer is not administered within 5 minutes, patient begins to use sternocleidomastoid muscles visibly and RR increases to 32/min.)
! (If trainee attempts nebulised salbutamol, facilitator advises: 'We do not have a nebuliser available — you have a Ventolin MDI and spacer at the FAP.' Redirect to MDI via spacer.)
! (If trainee asks about patient's own puffer, confirm it is not present — EHS must use their own FAP salbutamol MDI and spacer.)
! (If trainee does not sit the patient upright, patient states 'I can't breathe lying down — please let me sit up.')

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform Primary Survey — confirm patent airway, identify severe respiratory distress.
3. Position patient sitting upright or in position of comfort — do NOT lay flat.
4. Apply pulse oximetry and obtain baseline SpO2 (90% RA).
5. Administer oxygen via simple face mask at 5–8 L/min — titrate SpO2 to target 92–95%.
6. Obtain full vital signs: RR, HR, BP, SpO2, GCS, temp.
7. Perform history taking — SAMPLEE including known asthma, no puffer present, no known drug allergies.
8. Administer Salbutamol (Ventolin) 4–12 puffs (400–1200 microg) via MDI and spacer — indication: severe bronchospasm in acute asthma exacerbation. Shake MDI well before use. Administer 1 puff at a time, 4 breaths per puff, up to 12 puffs based on clinical response.
9. Reassess respiratory rate, SpO2, and work of breathing 5 minutes after salbutamol administration.
10. If insufficient response after initial salbutamol dose, repeat 4–12 puffs via MDI and spacer every 20 minutes as clinically indicated.
11. Monitor patient persistently — record full observations every 10 minutes.
12. Reassure patient continuously throughout.
13. Recognise indications for Priority 1 transport: life-threatening features (reduced consciousness, cyanosis, SpO2 <90%, poor respiratory effort, exhaustion, soft/absent breath sounds) — call for ambulance if present or if no improvement with treatment.
14. Document clinical findings, interventions, and response on patient care record.
15. Scenario ends on arrival of ambulance and IMISTAMBO handover.
16. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Asthma exacerbation · Salbutamol Sulphate · Oxygen · MDI & Space Chamber

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Signs/Symptoms	Wheeze, shortness of breath, chest tightness, difficulty completing sentences.
Allergies	Nil known drug allergies. No known allergy to salbutamol.
Medications	Salbutamol (Ventolin) MDI — own puffer not with her today. Fluticasone/salmeterol (Seretide) preventer — taken this morning.
Pertinent History	Known asthma for 40 years. No prior ICU admissions or intubations. No hospital admissions for asthma in the past 12 months. No use of oral steroids long-term.
Last Oral Intake	Lunch approximately 2 hours ago — sandwich and water.
Events Leading	Walking around the Perth Royal Show exhibitor halls. Noted dusty environment and animal dander. Became progressively breathless and walked to the FAP.
Treatment Prior	Nil. Does not have her puffer with her.

Onset	Gradual onset over the last 20 minutes. Worsened after walking briskly through the showgrounds.
Pain	Mild chest tightness rated 3/10. No sharp or crushing chest pain.
Quality	Tight, squeezing sensation across the chest. Describes breathing as 'like sucking through a straw'.
Radiates	Nil radiation.
Severity	3/10 chest tightness. Breathing difficulty described as severe.