Alternatively, the condition may be associated with chronic airflow obstruction and some symptoms may then be present continuously though of varying severity.
In severe attacks, the patient is extremely dyspneic, orthpneic and often cyanosed. He is agitated and may be confused. He is often most comfortable sitting forward with his arms leaning on some support, a point to remember when asking the patient to lean back on the pillows to be examined. There is indrawing of the soft tissues of the neck and the accessory muscles are active. The chest Pain is overinflated with diminished hepatic and cardiac dullness to percussion and respiratory movement is reduced. High pitched sibilant rhonchi which are often associated with coarse crepitations in some areas, occur during inspiration as well as expiration.
It is important to remember that when airflow obstruction becomes extreme, rhonchi may disappear. The pulse is rapid and blood pressure is normal. The sputum is usually viscid and difficult to expectorate. If the attack has been present for many hours or days without remission despite treatment, the patient has status asthmaticus. This is often associated with signs of exhaustion and dehydration. Tachycardia is the rule and if greater than 130 per minute, indicates severe hypoxemia. Rarely, in patients with very prolonged airflow obstruction, edema of the feet and ankles may occur without other clinical evidence of heart failure.
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