Simulated Patient Scenario

Paediatric Asthma Exacerbation

Scenario Details

Scenario: Moderate-Severe Asthma Exacerbation

Simulated Patient: 8-year-old Child (Mannequin or Actor)

Actor/Actress: Parent (present on scene)

MDT Information

Urgent Response - Difficulty Breathing
8-year-old child, known asthmatic
Increased work of breathing, audible wheeze
Using reliever puffer with minimal effect
Patient is conscious and alert, distressed
Location: Home address

On Arrival

You arrive at a house where an anxious parent meets you at the door. They lead you to the living room where their 8-year-old child is sitting upright on the sofa, leaning forward (tripod position). The child appears anxious, is breathing rapidly, and you can hear audible wheezing. They are using accessory muscles (intercostal/subcostal retractions). A blue reliever puffer and spacer are on the table nearby.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Alert child in moderate-severe respiratory distress, anxious, audible wheeze.
Response	Alert, anxious, speaking in short sentences (3-4 words). (AVPU = A)
Airway	Clear and self-maintaining, but audible wheeze present.
Breathing	Markedly increased work of breathing: Tachypnoea, accessory muscle use (intercostal/subcostal recession), audible wheeze, prolonged expiratory phase.
Circulation	Skin pale, warm peripherally. Tachycardic. Cap refill < 2 sec.
Disability	Alert (GCS 15), anxious.
Exposure/Environment	Indoor home environment. Reliever medication visible.

Secondary Survey and Simulation Progression

History (obtained from parent and child)

Allergies	NKDA (Parent confirms)
Medications	Salbutamol (Ventolin) MDI via spacer PRN. Fluticasone (Flixotide) MDI via spacer daily (preventer).
Past Medical History	Asthma (diagnosed age 3). Several previous ED presentations for asthma, one hospital admission last year. Has an Asthma Action Plan.
Last Oral Intake	Breakfast ~4 hours ago. Sips of water since.
Events Preceding	Child developed a mild cough and runny nose yesterday. Symptoms worsened overnight with increased coughing. Woke this morning feeling tight-chested and wheezy. Parent administered Salbutamol via spacer (e.g., 6 puffs) ~1 hour ago, and again 20 minutes ago with only minimal, short-lived improvement. Symptoms have progressively worsened over the last hour. Denies fever. Known trigger: viral infections.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	36 (Tachypnoeic)
Lung Sounds (L/R)	Widespread polyphonic expiratory wheeze bilaterally. Reduced air entry possible if severe.
SpO2 (%)	92% (Room Air)
EtCO2 (mmHg)	Low initially (e.g., 30 mmHg) due to tachypnoea. (Normal/Rising EtCO2 in severe exhaustion is an ominous sign).
Pulse Rate (/min.)	130, regular (Tachycardic)
CRT (sec.)	< 2 sec
ECG rhythm	Sinus Tachycardia
12-lead ECG	Not typically indicated unless concern for cardiac cause.
BP (mmHg)	110/70 (Normal for age)
Skin	Pale, warm, dry.
Pain (/10)	Reports chest tightness, no specific pain score.
GCS (/15: E,V,M)	15/15 (E4, V5 - short sentences, M6)
BGL (mmol/L)	Not indicated unless altered LOC.
Pupils (mmL/mmR)	3mm L / 3mm R, Equal and Reactive (PERL)
Temp. (°C)	37.2

Physical Examination

General Appearance: Anxious child in respiratory distress, sitting upright (tripod), speaking in short sentences.
Respiratory: Tachypnoea, significant accessory muscle use (intercostal, subcostal, possibly supraclavicular retractions). Audible expiratory wheeze. Widespread wheeze on auscultation bilaterally, prolonged expiratory phase. Good air entry overall (Note: A silent chest is an ominous sign of severe obstruction).
Cardiovascular: Tachycardia. Pulses good.
Neurological: Alert, anxious, GCS 15.

Assessment and Treatment

Appropriate Management Focus

Primary Survey (ABCDE) & Severity Assessment: Recognize moderate-severe asthma exacerbation based on work of breathing, ability to speak, RR, HR, SpO2, auscultation findings.
Oxygen Therapy: Apply oxygen via face mask or nasal prongs to maintain SpO2 ≥ 94%. Titrate to patient comfort and SpO2.
Bronchodilator Therapy (First Line):
- Administer **Salbutamol** via nebuliser (driven by oxygen) or MDI with spacer according to local paediatric protocols (e.g., Nebuliser: 2.5mg or 5mg depending on age/weight; MDI: 6-12 puffs via spacer).
- Administer **Ipratropium Bromide** via nebuliser concurrently with Salbutamol for moderate-severe exacerbations (check local protocols for dose, e.g., 250mcg).
- Repeat Salbutamol +/- Ipratropium frequently (e.g., every 20 minutes) based on clinical response and protocols.
Corticosteroids: Consider early administration of corticosteroids per local protocol (e.g., oral Prednisolone if able to tolerate, or IV/IM Hydrocortisone/Dexamethasone). Often guided by severity and transport time.
Positioning: Allow patient to maintain position of comfort (usually sitting upright).
Monitoring: Continuous SpO2 monitoring. Frequent reassessment of respiratory status (work of breathing, RR, air entry, wheeze, ability to speak), HR, and overall clinical condition, especially after bronchodilator administration.
Consider IV Access: Establish IV access if severe distress, requiring IV medications, or potential for deterioration.
Magnesium Sulfate / Adrenaline: Reserved for severe/life-threatening asthma refractory to initial treatment, administered according to specific protocols and often after consultation.
Transport: Transport urgently to an Emergency Department equipped for paediatric emergencies. Pre-notify receiving hospital (Paediatric asthma exacerbation - severity, vitals, SpO2, treatments given, response).
Teamwork & Communication: Calm, reassuring approach to child and parent. Explain treatments. Clear handover.

Debrief Focus Points

Recognizing signs and symptoms of paediatric asthma exacerbation.
Paediatric asthma severity assessment (mild, moderate, severe, life-threatening).
Appropriate use of oxygen therapy.
First-line bronchodilator therapy (Salbutamol, Ipratropium Bromide) - routes (neb vs MDI/spacer) and dosing considerations.
Role and timing of corticosteroids.
Importance of frequent reassessment and monitoring response to treatment.
Recognizing signs of deterioration and impending respiratory failure (silent chest, exhaustion, cyanosis, altered mental state).
Management options for severe/life-threatening asthma (Magnesium, Adrenaline).
Communication strategies with children and anxious parents.