1.

Features of severe asthma:

• Cannot complete sentence in one breath.
• Respiration (per minute): 25 or more.
• Pulse (per minute): 120 or more.
• PEFR usually 33-50 % of predicted (refer to nomogram) or best.
2. Features of life threatening asthma:
• Silent chest, cyanosis, feeble respiratory effort.
• Bradycardia.
• Hypotension.
• Exhaustion, confusion or coma.
• PEFR usually less than 33 % of predicted or best (or a single reading of
<150L/min or patients who are not able to blow).
• ABG markers of very severe, life threatening atttack include:
- a normal (5-6kPa, or 36-45mmHg) or high PaCO2
- severe hypoxaemia (PaO2 <8kPa or 60mmHg) irrespective of treatment
with oxygen
- a low PH.

Acute exacerbation of COPD presents as a worsening of the previous stable

situation. Important symptoms include:
- Increased sputum purulence, increased sputum volume, increased
dyspnoea, increased wheeze, chest tightness and fluid retention.
• Most instance are precipitated by respiratory tract infections, both upper
and lower.

Pneumonia

”Typical” pneumonia - characterized by a sudden onset of illness with high

fever, sweats, rigors, pleuritic chest pain, cough, sputum production,
haemoptysis, dyspnoea, tachypnoea, tachycardia, pleural rub, rhonchi and
signs of consolidation and a ‘toxic’ appearance. Chest X-ray shows a lobar
or lobular opacity. White cell count is usually markedly elevated.
b. ”Atypical” pneumonia- characterized by a gradual onset of non-productive
cough, dyspnoea, constitutional symptoms and low grade fever. Clinical
findings are often minimal. White cell count is often not elevated. Chest Xray
characteristically show a diffuse bilateral pulmonary infiltrate which
appears worse than accounted for by the clinical signs.

Investigations
Investigations
1. General: FBC, BUSE, CXR, LFT, se creatinine, ABG, cold agglutinins (if
mycoplasma suspected), etc.
2. Microbiology diagnosis:
• Sputum culture and microscopy.
• Blood culture.
• Acid fast bacilli.
• Pleural aspiration for analysis and cultures if effusion is present.
• Bronchoscopy should be considered in solitary lung abscess.
• Serology (or serum antibody titres) for mycoplasma, chlamydia, legionella
or viruses when atypical pneumonia is suspected. A rising titre over a 2
week interval may provide a retrospective diagnosis. Persistently high
antibody titre can also be suggestive.
• Immunofluorescence or Giemsa stain for pneumocystis carinii from
induced sputum or bronchial lavage specimens.