Scenario — Acute asthma exacerbation in elderly male

foundation Respiratory · Elderly · 75yr · male

Patient Information

Dispatch	You are called to a 75YO male at the First Aid Post during the Perth Royal Show. Bystanders report he has been coughing and struggling to breathe for the past 10 minutes. (Ray Hutchinson)
Patient	Ray Hutchinson — 75yr (75kg)
Incident History	Pt was walking through the showgrounds when he developed sudden onset wheeze and shortness of breath. A bystander escorted him to the FAP. Pt states he has asthma and left his puffer at home.
Emergency Contact	Margaret Hutchinson (Wife) — 0412 883 547

Response	Alert
Airway	Patent. Nil airway obstruction. Nil stridor. Audible wheeze on expiration.
Breathing	Increased work of breathing. Accessory muscle use noted. Unable to complete sentences in one breath. RR 26/min. Audible expiratory wheeze bilaterally.
Circulation	Radial pulse present — rapid and regular. Skin pale and slightly diaphoretic. Nil bleeding.
Disability	GCS 15 (E4V5M6). Orientated to time, place and person. Anxious.
Exposure	Nil rashes or visible injuries. No medical alert bracelet noted.

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	91% (RA)	Moderate	26	108	148/88	<2s	15	4 4 ++	36.8	–	3
10 mins	95% (O2 simple mask 6L/min)	Mild	20	98	142/84	<2s	15	4 4 ++	36.8	–	2

Diagnosis

This patient is suffering from a moderate acute asthma exacerbation.

Facilitator Triggers — if trainees miss a critical step

! (If oxygen is not applied within 3 minutes of arrival, SpO2 drops to 89% and the patient becomes more distressed and agitated — prompt trainee: 'He looks worse, what do you want to do?')
! (If trainee does not sit the patient upright and instead lays him flat, patient reports feeling more breathless — redirect: 'He says lying down makes it worse.')
! (If trainee does not source a Ventolin MDI and spacer from the FAP kit, remind them: 'What medications do you have available at the FAP?')
! (If trainee asks about the patient's own puffer, confirm he does not have it — EHS must use the FAP-supplied Salbutamol MDI and spacer.)
! (If 10-minute vitals are not reassessed after Salbutamol, prompt: 'It has been 10 minutes — how is he responding to treatment?')

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform Primary Survey — confirm patent airway with audible wheeze, moderate respiratory distress, and adequate circulation.
3. Position patient sitting upright or in a position of comfort — do NOT lay flat.
4. Apply oxygen via simple face mask at 5–8 L/min — titrate SpO2 to target 92–95% for adults.
5. Perform Vital Sign Survey — record RR, SpO2, HR, BP, GCS, pain score.
6. Determine severity of asthma exacerbation using the severity classification table — classify as moderate based on accessory muscle use, inability to complete sentences, and SpO2 91%.
7. Assess for risk factors associated with increased risk of asthma-related death — nil high-risk features identified in this patient.
8. Administer Salbutamol (Ventolin) 400–1200 microg (4–12 puffs) via MDI and spacer — indication: bronchospasm in acute asthma. Administer one puff at a time, instruct patient to take 4 breaths per puff.
9. Reassess SpO2, RR, and respiratory effort after Salbutamol — repeat every 20 minutes for the first hour if required.
10. Record full observations every 10 minutes.
11. Arrange transport to hospital — this patient requires ED review even if symptoms improve.
12. Monitor persistently for rapid deterioration to severe or life-threatening exacerbation.
13. Scenario ends on arrival of ambulance and IMISTAMBO handover.
14. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Asthma exacerbation · Salbutamol Sulphate · Oxygen · MDI & Space Chamber · Primary Survey · Pulse Oximetry

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Signs/Symptoms	Wheeze, shortness of breath, chest tightness, persistent cough.
Allergies	Nil known drug allergies.
Medications	Salbutamol MDI (Ventolin) — prescribed, not on his person today. Irbesartan for hypertension. Atorvastatin.
Pertinent History	Known asthmatic for 20 years. Well-controlled at baseline. No prior ICU admissions. No prior intubations. Occasional use of puffer — usually less than one canister per month.
Last Oral Intake	Lunch approximately 2 hours ago.
Events Leading	Pt was walking between pavilions at the Perth Royal Show when he began coughing and felt his chest tighten. Symptoms worsened over 10 minutes.
Treatment Prior	Nil. Does not have his puffer with him.

Onset	Sudden onset approximately 10 minutes ago while walking through the showgrounds.
Pain	Chest tightness only — not cardiac-type pain.
Quality	Tight chest with expiratory wheeze. Cannot finish sentences without pausing.
Radiates	Nil
Severity	6/10 chest tightness