Thoracic & Respiratory

A 28-year-old woman with a known history of asthma, including one previous ICU admission for intubation, presents to the emergency department with acute breathlessness that began several hours ago after running out of her preventer inhaler. She is sitting bolt upright, unable to speak in full sentences, and using accessory muscles of respiration. Observations show respiratory rate 32/min, heart rate 128/min, blood pressure 118/76 mmHg, and SpO2 89% on room air. Widespread expiratory wheeze is audible throughout both lung fields, and peak expiratory flow is 35% of her predicted best. She appears anxious but is fully alert and oriented. What is the most appropriate initial management?

A 58-year-old man with poorly controlled type 2 diabetes and a history of heavy alcohol use presents to the emergency department with a 4-day history of fever, rigors and productive cough. He returned 10 days ago from a holiday in rural Thailand, where he worked in rice paddies and waded in flooded fields. On examination he is unwell, temperature 39.2°C, heart rate 118/min, blood pressure 88/54 mmHg, respiratory rate 28/min and SpO₂ 90% on room air. Chest auscultation reveals crackles at the right upper zone, and chest X-ray shows a cavitating consolidation with multiple small nodular opacities. Blood glucose is 22 mmol/L. In addition to standard broad-spectrum community-acquired pneumonia cover, which of the following is the MOST important additional consideration in his empirical management?

A 35-year-old man with no childhood history of asthma or atopy presents to the emergency department with a 3-day history of worsening dyspnoea, wheeze and cough productive of thick white sputum. He was diagnosed with asthma only one month ago and has been using his salbutamol inhaler more than 10 times daily with minimal relief. On examination he is tachypnoeic (RR 28/min), speaking in short sentences, with widespread expiratory wheeze but no silent chest. Observations: SpO2 93% on room air, HR 110/min, BP 130/85 mmHg, temperature 36.8°C. He denies fevers, purulent sputum discolouration or sick contacts. Chest X-ray shows hyperinflation without focal consolidation. Full blood count reveals a peripheral eosinophil count of 1.8 × 10^9/L (reference <0.5 × 10^9/L). His GP had already escalated therapy to a maximal inhaled corticosteroid/long-acting beta-agonist/long-acting muscarinic antagonist combination one month ago, with minimal improvement in symptom control since. Which of the following is the most appropriate next step in his ongoing management?

A 20-year-old man with cystic fibrosis (baseline FEV1 45% predicted) presents to the emergency department with sudden-onset right-sided pleuritic chest pain and worsening dyspnoea over the past two hours. He denies trauma. On examination he is tachypnoeic at 24 breaths/min, heart rate 110 bpm, blood pressure 118/76 mmHg, and SpO2 91% on room air (baseline 94%). There is reduced air entry and hyperresonance over the right hemithorax, with the trachea central. A chest X-ray confirms a right-sided pneumothorax with a 4 cm rim of air at the level of the hilum, and no mediastinal shift. He is haemodynamically stable but visibly distressed. What is the most appropriate next step in management?

A 50-year-old man with a background of poorly controlled asthma presents to the emergency department with acute severe breathlessness that began several hours after running out of his preventer inhaler. He is sitting upright, speaking in short phrases, and using accessory muscles, with a respiratory rate of 32/min, heart rate 118 bpm, blood pressure 132/78 mmHg, and SpO2 91% on 6 L/min oxygen via mask. Auscultation reveals diffuse expiratory wheeze with good air entry bilaterally, and peak expiratory flow is 45% of predicted. He remains alert, cooperative and able to protect his airway. Continuous nebulised salbutamol and ipratropium, intravenous hydrocortisone, and intravenous magnesium sulfate have been commenced, but he remains distressed and tachypnoeic after 30 minutes. The treating team considers a trial of non-invasive ventilation (BiPAP) while awaiting response to medical therapy. Which of the following best describes the current evidence base for NIV use in this setting?

A 24-year-old woman who is 28 weeks pregnant (G1P0) presents to the emergency department with a 2-day history of worsening dyspnoea, cough and wheeze following a viral upper respiratory tract infection. She has a background of poorly controlled asthma and has been using her salbutamol inhaler every 2 hours with minimal relief. On examination she is anxious and using accessory muscles, with a respiratory rate of 28/min, heart rate 112/min, blood pressure 118/72 mmHg and SpO2 92% on room air. Auscultation reveals widespread expiratory wheeze with reduced air entry bilaterally. She is commenced on nebulised salbutamol and ipratropium bromide with supplemental oxygen. Which corticosteroid regimen is most appropriate at this stage?