You are the medical registrar called to review a 28-year-old with worsening asthma. Talk us through your assessment and management.

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I would start with an immediate A–E assessment focusing on airway, work of breathing, SpO2, RR, HR, BP and conscious level, treating this as a medical emergency. Red flags I would look for include inability to speak in full sentences, silent chest, exhaustion or altered mental state, SpO2 below 92%, and PEFR under 33% predicted. My working diagnosis is acute severe asthma with potential progression to life-threatening asthma. Immediate management: oxygen titrated to 94–98%, back-to-back nebulised salbutamol with nebulised ipratropium bromide, and IV hydrocortisone followed by oral prednisolone when safe. If response is poor I would give IV magnesium sulphate. Investigations: peak flow if tolerated, ABG if hypoxic or tiring, FBC, U&E, and CXR only if diagnostic uncertainty or suspicion of pneumothorax. I would involve the respiratory consultant early and alert ICU if there are life-threatening features, with close monitoring in a high-dependency setting. Once stabilised I would review inhaler technique, adherence and triggers, and ensure she leaves with a personalised asthma action plan, appropriate preventer therapy and respiratory follow-up. Intubation would be a last resort in ICU for worsening hypoxia, rising CO2, exhaustion or reduced consciousness, in discussion with anaesthetics and critical care.

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