Respiratory and Thoracic Emergencies
Asthma and COPD
Assess severity by ability to speak, respiratory rate, heart rate, peak flow and mental state. A silent chest, exhaustion, cyanosis, bradycardia or altered consciousness means life-threatening asthma: senior help, continuous nebulised salbutamol with ipratropium, systemic corticosteroids, and magnesium sulphate 2 g IV over 20 minutes. Consider IV salbutamol, aminophylline and ketamine. Avoid sedation and avoid non-invasive ventilation in the exhausted patient; intubate with the largest tube possible, anticipating high airway pressures and post-intubation hypotension.
COPD exacerbation: target SpO2 88–92% in known CO2 retainers, nebulised bronchodilators, steroids, antibiotics if sputum is purulent, and early NIV for pH 7.25–7.35 with hypercapnia. Contraindications to NIV include pneumothorax, vomiting, facial trauma and reduced consciousness.
Pulmonary embolism: use a validated score with age-adjusted D-dimer in low-risk patients; massive PE with shock needs thrombolysis or embolectomy, not anticoagulation alone.
Pneumothorax: tension is a clinical diagnosis - needle decompression at the 5th intercostal space anterior axillary line, then a drain in the triangle of safety (5th intercostal space, mid-axillary line, bordered by pectoralis and latissimus).
Pneumonia: CURB-65 guides site of care; antibiotics within 4 hours for severe community-acquired pneumonia.
Rule of thumb: any breathless patient who cannot complete a sentence needs immediate senior review and continuous monitoring.