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WHEEZE/TIGHT CHESTInitial Management• Give salbutamol (beta-agonist) via:--Large-volume spacer: 4–8 puffs every 20 minutes for 1 hour then reassess, or--Nebuliser (oxygen-driven nebuliser is preferable) 1 : 1 or 2ml of 0.5% salbutamol solution in 3ml of sodium chloride 0.9% solution every 20 minutes for 1 hour.• Give first dose of oral prednisone 2 40mg if no immediate response, or is currently taking oral prednisone. If prednisone unavailable or patient unable to take it,give hydrocortisone 100mg IV.After 1 hour assess if patient has respiratory distress 16.WorseRefer immediately. While waiting for transport:• Add 2ml ipratropium bromide to salbutamolnebuliser solution.• Continue nebulisation every 20 minutes with oxygenin between. 3No change• Add 2ml ipratropium bromide to salbutamol solution.• Continue nebulisation or large volume spacer every 20minutes with oxygen in between. 3• Refer immediately if no response within 3 hours of arrival.• If improved, follow discharge plan below.Better or no symptoms• If stable after 1 hour, follow discharge plan below.Discharge plan for the patient who has responded to treatment• Start, or increase dose and frequency of inhaled salbutamol to a maximum of 2 puffs 4 times a day until condition improves. Check inhaler technique 65.• If patient received oral prednisone or IV hydrocortisone above, give oral prednisone 40mg daily for 6 more days.• If patient has fever, increased sputum production or a change in sputum colour give amoxicillin 1g 8 hourly for 5 days. If penicillin allergic, give erythromycin 500mg 6 hourly for 5 daysinstead.• Ask about allergic rhinitis/hayfever (sneezing, itchy or runny nose): treating hayfever effectively improves asthma symptoms 13.• People are more likely to stop smoking if advised to do so by a health professional. Urge your patient to stop smoking. For tips on communicating effectively see Preface.• Book follow-up visits before medicines are expected to run out.Treat according to known diagnosis (see below). If the cause of wheezing is not known 65.Known asthma• Start inhaled corticosteroid 66 if 2nd emergency visit for asthma in 6 monthsor previously using inhaled corticosteroid.• If already on inhaled corticosteroid, adjust dose 66.• Give oral prednisone 40mg daily for 7 days if:--Recent/frequent emergency visits or previous hospital admission for asthma.--Worsening of symptoms in the months or weeks leading up to the exacerbation.• Refer same week to doctor if: no response to 7 days of oral prednisone in past 4weeks, more than 2 courses of oral prednisone in the last 6 months, or exacerbationoccurs in spite of maximum level of chronic treatment.• Follow up the asthma patient 66.Known copd• Give oral prednisone 40mg daily for 7 days if:--Breathlessness has improved but remains worse than usual.--Patient has been on long-term daily oral prednisone.• Refer same month to doctor if 2 or more exacerbations in6 months.• Follow up the COPD patient 67.Tell patient to return before follow-up appointment if no improvement after completing a short course of oral prednisone.1If an oxygen-driven nebuliser is not available, use an air-driven nebuliser instead and give facemask oxygen between nebulisation. 2 Oral prednisone is an important component in the management in all but the mildest exacerbations.3Continuous nebulisation is better if there is an inadequate response to initial treatment.17