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Asthma exacerbations
  1. A Woodcock
  1. Professor A Woodcock, University of South Manchester, Southmoor Rd, Manchester M23 9LT, UK; ashley.woodcock{at}

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In their excellent article on asthma exacerbations,1 Aldington Beasley, ask “…why there is such a huge discrepancy between the management of severe asthma recommended by evidence based guidelines, and that observed in clinical practice”.

Although the guidelines are in fact quite simple and straightforward, I think that non-specialist junior physicians in the emergency department are confused by the apparent complexity of, for example, fig 3 from their article reproduced from the British Thoracic Society guidelines, especially when faced with an extremely unwell patient with asthma.

For a number of years, I have taught a very simple “6 P rule” for the assessment of asthma:

  • PEFR—baseline and response to first nebuliser.

  • Pulse, >120 (it is not due to salbutamol).

  • pO2 (measure and then titrate oxygen against O2 saturation).

  • Panic (ie, ability to speak/respiratory rate).

  • Paradox (patients cannot sustain this for long).

  • Pneumothorax (make sure the trachea is central until you can obtain a chest x ray; and do not allow anyone to put in a subclavian line).

This is the basic information needed to assess severity, and decide on management, and it is more easily taught and remembered than a complex figure.


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  • Competing interests: None.

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