Scenario — Acute asthma exacerbation at AFL match

foundation Respiratory · Adult · 35yr · male

Patient Information

Dispatch	A 35YO male has walked into the FAP at Optus Stadium complaining of difficulty breathing. He states his chest feels tight and he has been wheezing for the past 15 minutes. (Marcus Daly)
Patient	Marcus Daly — 35yr (80kg)
Incident History	Pt was watching the AFL game when he developed progressive shortness of breath and wheeze. He reports a known history of asthma and has his Ventolin puffer with him but states it is not helping as much as usual.
Emergency Contact	Kylie Daly (Wife) — 0412 774 391

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil airway obstruction. Nil stridor. Nil swelling.
Breathing	Increased work of breathing. Audible wheeze bilaterally. Unable to complete full sentences without pausing. RR 26/min. SpO2 91% on room air.
Circulation	Radial pulse present, regular, slightly elevated rate. Skin pale and mildly diaphoretic. CRT 2s.
Disability	GCS 15 (E4V5M6). Alert and orientated to time, place and person. Anxious.
Exposure	No rashes, urticaria or angioedema visible. Accessory muscle use noted — intercostal and neck muscles.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	91% (RA)	Severe	26	112	130/82	2s	15	4 4 ++	37.1	–	4
10 mins	96% (O2 simple mask 6L/min)	Mild	18	98	126/80	<2s	15	4 4 ++	37.1	–	2

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a severe acute asthma exacerbation.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not apply oxygen within 2 minutes of assessment, SpO2 drops to 88% and patient becomes more agitated and distressed — prompt trainee: 'The patient grips the chair and says he cannot catch his breath.')
! (If trainees attempt to administer salbutamol without a spacer, facilitator informs them the EHS MDI spacer device is available at the FAP — direct trainee to use Space Chamber or Lite Aire spacer as per CPG.)
! (If trainees do not reassess the patient after the first salbutamol dose at 20 minutes, prompt: 'The patient says his chest still feels very tight and the wheeze has not improved much — what do you do next?')
! (If trainees do not request ambulance/higher-care backup for a severe exacerbation with SpO2 <92%, facilitator states: 'Your FAP supervisor asks whether this patient needs escalation — what is your decision?')
! (If trainees ask about using the patient's own puffer without a spacer, remind them the preferred route is MDI via spacer — patient's own medication may be used but via EHS spacer device.)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE.
2. Perform Primary Survey — confirm patent airway, severe breathing difficulty, circulation intact, GCS 15.
3. Position patient upright or in 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 — RR, SpO2, HR, BP, pain score.
6. Conduct SAMPLE history — confirm asthma diagnosis, current medications, triggers, prior hospitalisations or ICU admissions.
7. Assess severity of exacerbation using severity classification — wheeze, accessory muscle use, sentence completion, SpO2 — classify as SEVERE.
8. Administer Salbutamol (Ventolin) 400–1200 microg (4–12 puffs) via MDI and spacer — indication: bronchospasm in acute asthma.
9. Reassess after each 4-puff administration — monitor RR, SpO2, wheeze, ability to speak in full sentences.
10. Repeat Salbutamol 400–1200 microg (4–12 puffs) via MDI and spacer every 20 minutes or sooner if clinically indicated.
11. Request ambulance/higher-level backup given severe classification and SpO2 <92% on room air — this is a time-critical patient.
12. Record full observations every 10 minutes (or 5 minutes given time-critical status).
13. Continuously reassure patient and keep exertion minimal.
14. Prepare for rapid deterioration — have BVM and suction immediately available.
15. Do NOT ventilate unless patient loses ability to maintain adequate respiratory effort — if required, ventilate gently at no more than 4–6 breaths per minute to avoid air trapping.
16. Scenario ends on arrival of ambulance and IMISTAMBO handover.
17. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Asthma exacerbation · Salbutamol Sulphate · Oxygen · MDI & Space Chamber

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Signs/Symptoms	Shortness of breath, wheeze, chest tightness, accessory muscle use, unable to complete full sentences.
Allergies	Nil known drug allergies. Nil food allergies.
Medications	Salbutamol (Ventolin) MDI — PRN. Budesonide/formoterol inhaler — daily preventer (states he has not taken it for the past 3 days as he ran out).
Pertinent History	Diagnosed asthmatic for 12 years. No prior ICU admissions or intubations. No hospitalisations in past 12 months. Has used his Ventolin twice in the last hour with minimal relief.
Last Oral Intake	Meat pie and soft drink approximately 90 minutes ago.
Events Leading	Seated watching the AFL game. Noticed increasing chest tightness and wheeze. Cold air and grass pollen possibly contributing. Walked to the FAP when symptoms worsened.
Treatment Prior	Self-administered 2 puffs of own Ventolin MDI without spacer approximately 20 minutes ago — minimal relief.

Onset	Gradual onset over 15–20 minutes while seated watching the match.
Pain	Chest tightness rated 4/10 — described as pressure sensation across the chest.
Quality	Tight, constricting sensation across the chest with audible wheeze on both breathing in and out.
Radiates	Nil radiation.
Severity	4/10 chest tightness. Significant breathlessness — unable to complete full sentences.