Management of acute severe asthama essay note in it

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"acute severe asthma" management treatment

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I now have comprehensive content from Fishman's, Tintinalli's, and Rosen's. Let me compile a thorough essay note.

Management of Acute Severe Asthma

Definition and Classification

Acute severe asthma (status asthmaticus) is defined as a severe exacerbation that does not improve with usual doses of inhaled bronchodilators and corticosteroids. The GINA guidelines classify exacerbations by peak expiratory flow (PEF):

Mild: PEF >80% predicted
Moderate: PEF 60-80% predicted
Acute Severe: PEF <60% predicted
Life-threatening: PEF <30% predicted

Identifying High-Risk Patients

Certain patients are at increased risk for life-threatening events and near-fatal asthma:

History of frequent ED visits or prior hospitalizations
Previous intubation or mechanical ventilation for asthma
Severe and poorly controlled background disease
Use of more than 8 beta-agonist puffs in the previous 24 hours
Prior use of oral corticosteroids (OCS)

Patients commonly self-medicate with escalating doses of bronchodilator in the days before a fatal attack, which underscores the need for prompt medical attention and early corticosteroid use. - Fishman's Pulmonary Diseases and Disorders, p. 813

Clinical Features

Moderate exacerbation

Increased daytime and nocturnal cough, chest tightness, wheezing, dyspnea
Poor response to usual maintenance therapy
Fall in home peak flow recordings

Acute severe

Severe dyspnea; unable to speak in full sentences (speech fragmented into words or syllables)
Agitation, diaphoresis, tachypnea, tachycardia
Accessory muscle use; chest hyperinflation
Pulsus paradoxus (systolic BP fall >10 mmHg on inspiration)
Prodromal symptoms: itching under the chin, interscapular discomfort, feeling of impending doom

Life-threatening features

Silent chest (severe obstruction with minimal air movement - ABSENT wheeze)
Cyanosis, confusion/altered consciousness, exhaustion
Bradycardia, hypotension
SaO2 <92%, PaO2 <60 mmHg (8 kPa)
Rising PaCO2 = impending respiratory failure (initially PaCO2 is LOW due to hyperventilation; normalization or rise is ominous)

A rising PaCO2 indicates impending respiratory failure and requires immediate monitoring and therapy. - Fishman's, p. 812

Initial Assessment

PEF or FEV1: Assess severity and response to treatment
Pulse oximetry: Continuous monitoring; target SpO2 94-98%
Arterial blood gas (ABG): In life-threatening cases; assess PaO2, PaCO2, pH
CXR: Not routinely indicated; obtain only if suspected pneumothorax, consolidation, failure to respond, or need for mechanical ventilation
No single laboratory marker identifies near-fatal asthma - clinical judgment is paramount

Management

1. Oxygen

Deliver oxygen at high concentrations by face mask to maintain SpO2 between 94% and 98%. Hypoxemia must be avoided at all costs - patients die from hypoxemia. Continuous SpO2 monitoring is required until a meaningful clinical response is achieved. - Fishman's Pulmonary Diseases and Disorders, p. 812

2. Short-Acting Beta-2 Agonists (SABA) - First-Line

High-dose inhaled SABA (e.g., salbutamol/albuterol) are the cornerstone of acute management and should be given as early as possible:

Nebulizer: Oxygen-driven nebulization; can be given continuously in severe cases
pMDI with spacer: Equally effective as nebulizer in cooperative patients
In severely ill patients with impending respiratory failure or inability to use inhaled therapy reliably: intravenous beta-2 agonists (e.g., IV salbutamol)
If parenteral adrenergic therapy is chosen, terbutaline is preferred for its beta-2 selectivity (Rosen's EM)
Continuous ECG monitoring is required as nebulized bronchodilators can rarely cause arrhythmias

3. Systemic Corticosteroids (CS) - Mandatory

Exacerbations must never be treated with bronchodilators alone.

Oral prednisone: 40-50 mg once daily (if oral route tolerated)
IV methylprednisolone: 125 mg IV (if unable to take oral route)
IV hydrocortisone: Alternative parenteral option
Duration: At least 5 days or until recovery; taper over 2 weeks after severe exacerbations
Early administration is critical to reduce the risk of death

4. Anticholinergics - Add-On Therapy

Ipratropium bromide nebulized: Added to SABA when the patient is not responding to initial bronchodilator therapy
Muscarinic receptor antagonists induce airway smooth-muscle relaxation by blocking cholinergic bronchoconstriction, providing additional bronchodilation beyond SABA alone
Fishman's Pulmonary Diseases and Disorders, p. 812

5. Intravenous Magnesium Sulfate

Dose: 1-2 g IV over 20-30 minutes (single dose)
Indicated in:
- Acute severe asthma (FEV1/PEF <25% predicted) not responding to initial bronchodilator therapy
- Any patient with life-threatening features
Nebulized magnesium sulfate may also improve pulmonary function as an adjunct to beta-agonist and corticosteroid therapy in severe cases
Monitor blood pressure and deep tendon reflexes during administration - hypotension or neuromuscular blockade are rare but possible
Tintinalli's Emergency Medicine, p. 507

6. Additional / Second-Line Agents

Agent	Notes
IV aminophylline	Can be used but risks of toxicity are much greater than inhaled beta-2 agonists; use with caution
Heliox (helium-oxygen)	Reduces turbulent flow resistance; considered in refractory cases
IV ketamine	Bronchodilator properties; used as induction agent for RSI

Agents to AVOID:

Sedatives: Never give - they depress ventilation
Antibiotics: Not routinely indicated unless clinical/radiologic evidence of pneumonia

7. Monitoring During Treatment

Continuous pulse oximetry and ECG monitoring
Serial PEF measurements to assess response
ABG in life-threatening or deteriorating patients
Response to treatment guides disposition

Non-Invasive Ventilation (NIV)

BiPAP (bilevel positive airway pressure) is the preferred non-invasive modality:

Reduces work of breathing; stents airways open; improves gas exchange; has a bronchodilator effect
Initial settings: IPAP 12 cm H2O / EPAP 6 cm H2O (ranges: IPAP 12-18; EPAP 6-12 cm H2O)
Aerosolized medications can be administered through the BiPAP circuit
Sedation if needed: low-dose midazolam 0.05-0.1 mg/kg, lorazepam, or ketamine 0.5-1 mg/kg
Can prevent the need for endotracheal intubation even when applied for only a few hours
Tintinalli's Emergency Medicine, p. 508

Endotracheal Intubation and Mechanical Ventilation

Indicated when acute severe or life-threatening asthma fails to respond to maximal medical therapy, with:

Deteriorating PEF
Worsening or refractory hypoxemia
Normal or rising PaCO2
Poor respiratory effort, somnolence, or exhaustion
Hemodynamic instability

RSI Drug Protocol for Near-Fatal Asthma

Drug	Role	Dose
Ketamine	Induction (bronchodilator effect)	2 mg/kg IV
Succinylcholine	Short-term paralysis	<10 kg: 2 mg/kg; >10 kg: 1.5 mg/kg
Rocuronium	Non-depolarizing alternative	1 mg/kg

Use the largest appropriate cuffed endotracheal tube
Preoxygenate with 100% oxygen
Give a normal saline bolus (20 mL/kg) before intubation to minimize hypotension
Intubate the patient in the sitting-up or semirecumbent position

Ventilator Strategy - Permissive Hypercapnia

The goal is to minimize dynamic hyperinflation (air trapping) and barotrauma:

Low tidal volume (6-8 mL/kg)
Slow respiratory rate (10-14 breaths/min) with prolonged expiratory time (high I:E ratio ~1:3 to 1:4)
Low PEEP (or zero PEEP initially) - avoid worsening air trapping
Accept elevated PaCO2 (permissive hypercapnia) rather than risk barotrauma
Peak inspiratory pressures should be monitored closely

Unrecognized barotrauma may cause cardiac arrest. Bedside ultrasound should be used to identify occult pneumothorax. Empirical bilateral tube thoracostomy should be performed if unexplained cardiac arrest occurs in the context of dramatic increases in peak inspiratory pressure. - Rosen's Emergency Medicine, p. 2122

ECMO

Extracorporeal membrane oxygenation (ECMO) may be indicated for severe asthma refractory to all conventional therapies, including mechanical ventilation. - Rosen's EM

Disposition from Emergency Department

Response	PEF (% predicted)	Disposition
Good	≥60%	Discharge home with follow-up
Incomplete	40-60%	Consider admission vs. observation based on risk factors
Poor	<40%	Hospitalize; continue aggressive therapy

Factors favoring hospital admission:

Female sex, older age, non-white race
Need for rapid intervention on arrival
RR >22; SpO2 <95%; final PEF <50% predicted
Previous intubation or admission for asthma
Prior use of OCS
More than 8 beta-agonist puffs in previous 24 hours

Discharge Checklist (if discharging from ED)

Prescribe SABA: e.g., albuterol 2-6 puffs every 4 hours until symptoms fully resolve
Oral corticosteroids: prednisone 40 mg daily x 5 days
Ensure proper MDI technique (use spacer/holding chamber)
Prescribe or ensure ICS for maintenance
Peak flow meter (am/pm monitoring) for selected patients
Written asthma action plan
Follow-up appointment within 7 days of discharge
Tintinalli's Emergency Medicine, p. 507

Summary Algorithm

ACUTE SEVERE ASTHMA (PEF <60% predicted)
         |
         v
Oxygen → SpO2 94-98%
         |
         v
SABA (salbutamol) - nebulized or pMDI + spacer (high dose, early)
+ Systemic CS (prednisolone PO or methylprednisolone/hydrocortisone IV)
         |
         v
Not responding?
Add ipratropium bromide (anticholinergic)
IV/SC beta-2 agonist if inhaled route unreliable
IV magnesium sulfate 1-2g over 20-30 min
         |
         v
Life-threatening features / Failing maximal therapy?
Consider BiPAP (IPAP 12-18 / EPAP 6-12)
         |
         v
Deteriorating despite BiPAP / Impending arrest?
RSI with ketamine + ETI + Mechanical ventilation
(Permissive hypercapnia strategy)
         |
         v
Refractory to all → Consider ECMO

Key Principles to Remember:

Never treat exacerbations with bronchodilators alone - corticosteroids are always required
A silent chest is more dangerous than loud wheezing - it signals near-complete obstruction
Normal or rising PaCO2 in a breathless asthmatic = impending respiratory failure
Avoid sedatives; use ketamine if sedation is unavoidable during intubation
Hypoxemia kills - maintain SpO2 94-98% with high-flow oxygen throughout

Sources: Fishman's Pulmonary Diseases and Disorders (pp. 812-813) | Tintinalli's Emergency Medicine (pp. 507-509) | Rosen's Emergency Medicine (pp. 2118-2122)

Create a one-page quick reference PDF for acute severe asthma management

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mkdir -p /tmp/workspace/asthma-pdf && python3 << 'EOF' from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.units import mm, cm from reportlab.platypus import SimpleDocTemplate, Table, TableStyle, Paragraph, Spacer, HRFlowable from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY from reportlab.platypus import KeepTogether from reportlab.lib.colors import HexColor, white, black output_path = "/tmp/workspace/asthma-pdf/Acute_Severe_Asthma_QuickRef.pdf" # Custom colors RED = HexColor("#C0392B") DARK_RED = HexColor("#96281B") ORANGE = HexColor("#E67E22") YELLOW = HexColor("#F39C12") GREEN = HexColor("#27AE60") DARK_BLUE = HexColor("#1A5276") MID_BLUE = HexColor("#2471A3") LIGHT_BLUE= HexColor("#D6EAF8") LIGHT_RED = HexColor("#FADBD8") LIGHT_ORG = HexColor("#FDEBD0") LIGHT_GRN = HexColor("#D5F5E3") LIGHT_YLW = HexColor("#FEF9E7") GRAY_BG = HexColor("#F2F3F4") DARK_GRAY = HexColor("#2C3E50") MID_GRAY = HexColor("#5D6D7E") doc = SimpleDocTemplate( output_path, pagesize=A4, leftMargin=10*mm, rightMargin=10*mm, topMargin=8*mm, bottomMargin=8*mm ) W = A4[0] - 20*mm # usable width styles = getSampleStyleSheet() # Style helpers def S(name, **kw): base = styles["Normal"] return ParagraphStyle(name, parent=base, **kw) title_style = S("title", fontSize=14, textColor=white, alignment=TA_CENTER, fontName="Helvetica-Bold", leading=18) sub_style = S("sub", fontSize=8, textColor=white, alignment=TA_CENTER, fontName="Helvetica", leading=10) sec_hdr_style = S("sechdr", fontSize=7.5, textColor=white, fontName="Helvetica-Bold", leading=9, leftIndent=2) body_style = S("body", fontSize=6.8, textColor=DARK_GRAY, fontName="Helvetica", leading=8.5, leftIndent=3) bold_style = S("bold", fontSize=6.8, textColor=DARK_GRAY, fontName="Helvetica-Bold", leading=8.5, leftIndent=3) warn_style = S("warn", fontSize=6.8, textColor=RED, fontName="Helvetica-Bold", leading=8.5, leftIndent=3) small_style = S("small", fontSize=6.2, textColor=MID_GRAY, fontName="Helvetica", leading=7.5, leftIndent=3) arrow_style = S("arrow", fontSize=7, textColor=DARK_BLUE, fontName="Helvetica-Bold", leading=9, alignment=TA_CENTER) def section_header(text, bg_color): t = Table([[Paragraph(text, sec_hdr_style)]], colWidths=[W]) t.setStyle(TableStyle([ ("BACKGROUND", (0,0), (-1,-1), bg_color), ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2), ("LEFTPADDING", (0,0), (-1,-1), 4), ("RIGHTPADDING", (0,0), (-1,-1), 4), ("ROUNDEDCORNERS", [3, 3, 3, 3]), ])) return t def two_col_table(left_data, right_data, left_width=0.5, bg_l=GRAY_BG, bg_r=GRAY_BG): lw = W * left_width rw = W * (1 - left_width) data = [[left_data, right_data]] t = Table(data, colWidths=[lw, rw]) t.setStyle(TableStyle([ ("VALIGN", (0,0), (-1,-1), "TOP"), ("LEFTPADDING", (0,0), (-1,-1), 4), ("RIGHTPADDING", (0,0), (-1,-1), 4), ("TOPPADDING", (0,0), (-1,-1), 3), ("BOTTOMPADDING", (0,0), (-1,-1), 3), ("BACKGROUND", (0,0), (0,-1), bg_l), ("BACKGROUND", (1,0), (1,-1), bg_r), ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")), ])) return t story = [] # ────────────────────────────────────────────────────────── # TITLE BLOCK # ────────────────────────────────────────────────────────── title_tbl = Table([ [Paragraph("ACUTE SEVERE ASTHMA", title_style)], [Paragraph("Emergency Quick Reference | Status Asthmaticus", sub_style)], ], colWidths=[W]) title_tbl.setStyle(TableStyle([ ("BACKGROUND", (0,0), (-1,-1), DARK_BLUE), ("TOPPADDING", (0,0), (-1,-1), 4), ("BOTTOMPADDING", (0,0), (-1,-1), 4), ("LEFTPADDING", (0,0), (-1,-1), 6), ("RIGHTPADDING", (0,0), (-1,-1), 6), ])) story.append(title_tbl) story.append(Spacer(1, 3*mm)) # ────────────────────────────────────────────────────────── # ROW 1: SEVERITY + RECOGNITION (side by side) # ────────────────────────────────────────────────────────── story.append(section_header("▶ SEVERITY CLASSIFICATION (GINA)", MID_BLUE)) sev_data = [ [Paragraph("Grade", bold_style), Paragraph("PEF", bold_style), Paragraph("SpO2", bold_style), Paragraph("PaCO2", bold_style), Paragraph("Clinical", bold_style)], [Paragraph("Mild", body_style), Paragraph(">80%", body_style), Paragraph("≥95%", body_style), Paragraph("Low", body_style), Paragraph("Mild symptoms, speaks normally", body_style)], [Paragraph("Moderate", body_style), Paragraph("60–80%", body_style), Paragraph("92–95%", body_style), Paragraph("Low", body_style), Paragraph("Partial sentences, tachycardia", body_style)], [Paragraph("Acute Severe", bold_style), Paragraph("<60%", bold_style), Paragraph("<92%", bold_style), Paragraph("Low→Normal", bold_style), Paragraph("Single words, accessory muscles, pulsus paradoxus", bold_style)], [Paragraph("⚠ LIFE-THREATENING", warn_style), Paragraph("<30%", body_style), Paragraph("<92%", body_style), Paragraph("RISING ⚠", body_style), Paragraph("Silent chest, cyanosis, bradycardia, confusion, exhaustion", body_style)], ] cw = [W*0.15, W*0.09, W*0.09, W*0.13, W*0.54] sev_t = Table(sev_data, colWidths=cw) sev_t.setStyle(TableStyle([ ("BACKGROUND", (0,0), (-1,0), DARK_BLUE), ("TEXTCOLOR", (0,0), (-1,0), white), ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"), ("BACKGROUND", (0,3), (-1,3), LIGHT_ORG), ("BACKGROUND", (0,4), (-1,4), LIGHT_RED), ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")), ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2), ("LEFTPADDING", (0,0), (-1,-1), 3), ("RIGHTPADDING", (0,0), (-1,-1), 3), ("VALIGN", (0,0), (-1,-1), "MIDDLE"), ("FONTSIZE", (0,0), (-1,0), 6.8), ])) story.append(sev_t) story.append(Spacer(1, 2.5*mm)) # ────────────────────────────────────────────────────────── # ROW 2: STEPWISE MANAGEMENT # ────────────────────────────────────────────────────────── story.append(section_header("▶ STEPWISE MANAGEMENT", RED)) # Step boxes as a 5-column flow steps = [ ("STEP 1\nOXYGEN", "High-flow O2\nby face mask\nTarget SpO2\n94–98%\nContinuous\nmonitoring", GREEN), ("STEP 2\nSABA", "Salbutamol\nnebulized\n(O2-driven)\nor pMDI+spacer\nHigh dose,\nearly, repeat", MID_BLUE), ("STEP 3\nSTEROIDS", "Prednisolone\n40–50mg PO\nOR\nMethylpred.\n125mg IV\nMin. 5 days", ORANGE), ("STEP 4\nADD-ON Rx", "Ipratropium\nBromide neb.\n+\nIV Magnesium\n1–2g over\n20–30 min", HexColor("#8E44AD")), ("STEP 5\nBiPAP/ETI", "BiPAP:\nIPAP 12–18\nEPAP 6–12\ncmH2O\nRSI if failing\n(Ketamine 2mg/kg)", DARK_RED), ] step_cells = [] for (title, body, col) in steps: lines = [Paragraph(t if i == 0 else t, S(f"st{i}", fontSize=6.5 if i > 0 else 7, textColor=white if i == 0 else DARK_GRAY, fontName="Helvetica-Bold" if i == 0 else "Helvetica", alignment=TA_CENTER, leading=8.5)) for i, t in enumerate([title] + body.split("\n"))] cell_content = [Paragraph(title, S("stitle", fontSize=7, textColor=white, fontName="Helvetica-Bold", alignment=TA_CENTER, leading=9))] + \ [Paragraph(l, S("sbody", fontSize=6.3, textColor=DARK_GRAY, fontName="Helvetica", alignment=TA_CENTER, leading=7.8)) for l in body.split("\n")] step_cells.append(cell_content) # Build step table step_rows_content = [step_cells] step_t = Table([[col_content] for col_content in step_cells], colWidths=None) # Use a single row with 5 columns step_t2 = Table([step_cells], colWidths=[W/5]*5) step_t2_styles = [ ("TOPPADDING", (0,0), (-1,-1), 3), ("BOTTOMPADDING", (0,0), (-1,-1), 3), ("LEFTPADDING", (0,0), (-1,-1), 3), ("RIGHTPADDING", (0,0), (-1,-1), 3), ("VALIGN", (0,0), (-1,-1), "TOP"), ("GRID", (0,0), (-1,-1), 0.5, white), ] for i, (_, _, col) in enumerate(steps): step_t2_styles.append(("BACKGROUND", (i,0), (i,0), col)) step_t2.setStyle(TableStyle(step_t2_styles)) # Add white step headers row hdr_cells = [Paragraph(s[0], S(f"hdr{i}", fontSize=7, textColor=white, fontName="Helvetica-Bold", alignment=TA_CENTER, leading=9)) for i, s in enumerate(steps)] body_cells = [ [Paragraph(l, S("sb", fontSize=6.3, textColor=DARK_GRAY, fontName="Helvetica", alignment=TA_CENTER, leading=7.8)) for l in s[1].split("\n")] for i, s in enumerate(steps) ] # Rebuild with proper header + body split final_step_data = [hdr_cells] max_lines = max(len(b) for b in body_cells) for row_i in range(max_lines): row = [] for b in body_cells: if row_i < len(b): row.append(Paragraph(b[row_i], S("sbr", fontSize=6.3, textColor=DARK_GRAY, fontName="Helvetica", alignment=TA_CENTER, leading=7.8))) else: row.append(Paragraph("", body_style)) final_step_data.append(row) final_step_t = Table(final_step_data, colWidths=[W/5]*5) fs_styles = [ ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2), ("LEFTPADDING", (0,0), (-1,-1), 3), ("RIGHTPADDING", (0,0), (-1,-1), 3), ("VALIGN", (0,0), (-1,-1), "TOP"), ("GRID", (0,0), (-1,-1), 0.4, white), ("BACKGROUND", (0,1), (-1,-1), GRAY_BG), ("BOTTOMPADDING", (0, len(final_step_data)-1), (-1,-1), 4), ] for i, (_, _, col) in enumerate(steps): fs_styles.append(("BACKGROUND", (i,0), (i,0), col)) fs_styles.append(("TEXTCOLOR", (i,0), (i,0), white)) final_step_t.setStyle(TableStyle(fs_styles)) story.append(final_step_t) story.append(Spacer(1, 2.5*mm)) # ────────────────────────────────────────────────────────── # ROW 3: DRUGS TABLE + AVOID/MONITOR # ────────────────────────────────────────────────────────── lc = W * 0.58 rc = W * 0.42 # Drug table (left) story.append(section_header("▶ KEY DRUGS AT A GLANCE", HexColor("#117A65"))) drug_data = [ [Paragraph("Drug", bold_style), Paragraph("Route", bold_style), Paragraph("Dose", bold_style), Paragraph("Note", bold_style)], [Paragraph("Salbutamol (SABA)", body_style), Paragraph("Neb / pMDI", body_style), Paragraph("2.5–5mg neb q20min OR 4–8 puffs", body_style), Paragraph("1st line; O2-driven neb preferred", body_style)], [Paragraph("Salbutamol IV/SC", body_style), Paragraph("IV", body_style), Paragraph("250mcg slow IV; inf 3–20mcg/min", body_style), Paragraph("If inhaled route unreliable", body_style)], [Paragraph("Ipratropium bromide", body_style), Paragraph("Neb", body_style), Paragraph("0.5mg q20min x3 then q4–6h", body_style), Paragraph("Add-on if not responding to SABA", body_style)], [Paragraph("Prednisolone", body_style), Paragraph("PO", body_style), Paragraph("40–50mg once daily × ≥5 days", body_style), Paragraph("Taper over 2 wks if severe episode", body_style)], [Paragraph("Methylprednisolone", body_style), Paragraph("IV", body_style), Paragraph("125mg IV single dose then 40–80mg/day", body_style), Paragraph("Use if PO route not tolerated", body_style)], [Paragraph("MgSO4 (Magnesium)", body_style), Paragraph("IV", body_style), Paragraph("1–2g IV over 20–30 min", body_style), Paragraph("Life-threat / poor response to SABA; monitor BP & DTRs", body_style)], [Paragraph("Ketamine (RSI)", body_style), Paragraph("IV", body_style), Paragraph("2 mg/kg induction", body_style), Paragraph("Bronchodilator; preferred induction agent", body_style)], [Paragraph("Aminophylline", body_style), Paragraph("IV", body_style), Paragraph("5 mg/kg load over 20 min", body_style), Paragraph("Caution: narrow TI; monitor levels", body_style)], ] drug_cw = [W*0.22, W*0.12, W*0.30, W*0.36] drug_t = Table(drug_data, colWidths=drug_cw) drug_t.setStyle(TableStyle([ ("BACKGROUND", (0,0), (-1,0), HexColor("#117A65")), ("TEXTCOLOR", (0,0), (-1,0), white), ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"), ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, LIGHT_GRN]), ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")), ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2), ("LEFTPADDING", (0,0), (-1,-1), 3), ("RIGHTPADDING", (0,0), (-1,-1), 3), ("VALIGN", (0,0), (-1,-1), "MIDDLE"), ("FONTSIZE", (0,0), (-1,0), 6.8), ])) story.append(drug_t) story.append(Spacer(1, 2.5*mm)) # ────────────────────────────────────────────────────────── # ROW 4: VENTILATION + DISPOSITION + WARNINGS (3 col) # ────────────────────────────────────────────────────────── c1 = W * 0.34 c2 = W * 0.34 c3 = W * 0.32 vent_content = [ Paragraph("VENTILATION (BiPAP / ETI)", S("vh", fontSize=6.8, textColor=white, fontName="Helvetica-Bold", leading=9)), Spacer(1,1.5*mm), Paragraph("BiPAP indications: Poor response to max medical Rx; consider before intubation", body_style), Paragraph("• IPAP: 12–18 cm H2O", body_style), Paragraph("• EPAP: 6–12 cm H2O", body_style), Paragraph("• Nebulized drugs via BiPAP circuit", body_style), Paragraph("• Sedation: midazolam 0.05–0.1 mg/kg OR ketamine 0.5–1 mg/kg", body_style), Spacer(1,1.5*mm), Paragraph("Intubation indicators:", bold_style), Paragraph("• Deteriorating PEF + worsening SpO2", body_style), Paragraph("• Rising PaCO2 / respiratory exhaustion", body_style), Paragraph("• GCS deterioration / impending arrest", body_style), Spacer(1,1.5*mm), Paragraph("Vent strategy (permissive hypercapnia):", bold_style), Paragraph("• TV 6–8 mL/kg RR 10–14/min", body_style), Paragraph("• Prolonged expiratory time (I:E ≥ 1:3)", body_style), Paragraph("• Low PEEP; accept high PaCO2", body_style), Paragraph("• Watch for pneumothorax (bedside USS)", body_style), Paragraph("• ECMO if refractory to all Rx", body_style), ] disp_content = [ Paragraph("DISPOSITION FROM ED", S("dh", fontSize=6.8, textColor=white, fontName="Helvetica-Bold", leading=9)), Spacer(1,1.5*mm), Paragraph("Discharge home (PEF ≥60%):", bold_style), Paragraph("• SABA 2–6 puffs q4h till resolved", body_style), Paragraph("• Prednisolone 40mg OD × 5 days", body_style), Paragraph("• ICS prescribed/reviewed", body_style), Paragraph("• Written asthma action plan", body_style), Paragraph("• Follow-up within 7 days", body_style), Spacer(1,1.5*mm), Paragraph("Admit to ward (PEF 40–60%): if risk factors present", bold_style), Spacer(1,1.5*mm), Paragraph("Admit to ICU:", bold_style), Paragraph("• PEF <40% / not responding", body_style), Paragraph("• Life-threatening features", body_style), Paragraph("• Requires/nearing ventilation", body_style), Spacer(1,1.5*mm), Paragraph("Risk factors → admit:", bold_style), Paragraph("• Prior intubation / ICU admission", body_style), Paragraph("• RR >22, SpO2 <95% on arrival", body_style), Paragraph("• >8 SABA puffs in last 24h", body_style), Paragraph("• Prior OCS use", body_style), ] warn_content = [ Paragraph("⚠ WARNINGS & KEY POINTS", S("wh", fontSize=6.8, textColor=white, fontName="Helvetica-Bold", leading=9)), Spacer(1,1.5*mm), Paragraph("NEVER give:", warn_style), Paragraph("✗ Sedatives (depress ventilation)", body_style), Paragraph("✗ Antibiotics (unless pneumonia)", body_style), Paragraph("✗ Bronchodilators alone (always add steroids)", body_style), Spacer(1,1.5*mm), Paragraph("REMEMBER:", bold_style), Paragraph("★ Silent chest = worse than wheezing", body_style), Paragraph("★ Normal PaCO2 in breathless pt = danger sign", body_style), Paragraph("★ Rising PaCO2 = impending arrest", body_style), Paragraph("★ Hypoxemia kills – maintain SpO2 94–98%", body_style), Spacer(1,1.5*mm), Paragraph("MONITOR:", bold_style), Paragraph("• Continuous SpO2 + ECG (arrhythmia risk)", body_style), Paragraph("• Serial PEF every 20–30 min initially", body_style), Paragraph("• ABG if life-threatening or deteriorating", body_style), Paragraph("• BP + DTRs during MgSO4 infusion", body_style), Spacer(1,1.5*mm), Paragraph("CXR: not routine – only if:", bold_style), Paragraph("• Suspected pneumothorax", body_style), Paragraph("• Consolidation / no response to Rx", body_style), ] def box_col(content, bg_hdr): t = Table([[c] for c in content], colWidths=[None]) styles_list = [ ("TOPPADDING", (0,0), (-1,-1), 1.5), ("BOTTOMPADDING", (0,0), (-1,-1), 1.5), ("LEFTPADDING", (0,0), (-1,-1), 4), ("RIGHTPADDING", (0,0), (-1,-1), 4), ("BACKGROUND", (0,0), (0,0), bg_hdr), ("BACKGROUND", (0,1), (-1,-1), GRAY_BG), ("BOX", (0,0), (-1,-1), 0.5, HexColor("#BDC3C7")), ] t.setStyle(TableStyle(styles_list)) return t vent_box = box_col(vent_content, DARK_BLUE) disp_box = box_col(disp_content, HexColor("#117A65")) warn_box = box_col(warn_content, RED) bottom_t = Table([[vent_box, disp_box, warn_box]], colWidths=[c1, c2, c3]) bottom_t.setStyle(TableStyle([ ("VALIGN", (0,0), (-1,-1), "TOP"), ("LEFTPADDING", (0,0), (-1,-1), 2), ("RIGHTPADDING", (0,0), (-1,-1), 2), ("TOPPADDING", (0,0), (-1,-1), 0), ("BOTTOMPADDING", (0,0), (-1,-1), 0), ])) story.append(bottom_t) story.append(Spacer(1, 2*mm)) # ────────────────────────────────────────────────────────── # FOOTER # ────────────────────────────────────────────────────────── footer_t = Table([[ Paragraph("Sources: Fishman's Pulmonary Diseases | Tintinalli's Emergency Medicine | Rosen's Emergency Medicine", S("ft", fontSize=5.5, textColor=MID_GRAY, fontName="Helvetica", leading=7)), Paragraph("For clinical use under supervision of a licensed physician. Not a substitute for clinical judgment.", S("ft2", fontSize=5.5, textColor=RED, fontName="Helvetica-Oblique", leading=7, alignment=TA_CENTER)), ]], colWidths=[W*0.6, W*0.4]) footer_t.setStyle(TableStyle([ ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2), ("BACKGROUND", (0,0), (-1,-1), LIGHT_BLUE), ("BOX", (0,0), (-1,-1), 0.4, MID_BLUE), ])) story.append(footer_t) doc.build(story) print(f"PDF created: {output_path}") EOF

Writing File

~/asthma-pdf/build_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import mm
from reportlab.platypus import (SimpleDocTemplate, Table, TableStyle,
                                Paragraph, Spacer)
from reportlab.lib.styles import ParagraphStyle
from reportlab.lib.enums import TA_CENTER, TA_LEFT
from reportlab.lib.colors import HexColor, white, black

OUTPUT = "/tmp/workspace/asthma-pdf/Acute_Severe_Asthma_QuickRef.pdf"

# ── Colours ──────────────────────────────────────────────
C_DARK_BLUE  = HexColor("#1A5276")
C_MID_BLUE   = HexColor("#2471A3")
C_LIGHT_BLUE = HexColor("#D6EAF8")
C_RED        = HexColor("#C0392B")
C_DARK_RED   = HexColor("#96281B")
C_ORANGE     = HexColor("#E67E22")
C_GREEN      = HexColor("#1E8449")
C_PURPLE     = HexColor("#7D3C98")
C_TEAL       = HexColor("#117A65")
C_LIGHT_RED  = HexColor("#FADBD8")
C_LIGHT_ORG  = HexColor("#FDEBD0")
C_LIGHT_GRN  = HexColor("#D5F5E3")
C_GRAY_BG    = HexColor("#F2F3F4")
C_DARK_GRAY  = HexColor("#2C3E50")
C_MID_GRAY   = HexColor("#5D6D7E")
C_WHITE      = white

# ── Style factory ─────────────────────────────────────────
def P(text, size=6.8, color=C_DARK_GRAY, bold=False, italic=False,
      align=TA_LEFT, leading=None, left=2):
    fname = "Helvetica-Bold" if bold else ("Helvetica-Oblique" if italic else "Helvetica")
    if leading is None:
        leading = size + 1.8
    style = ParagraphStyle("_", fontSize=size, textColor=color,
                           fontName=fname, alignment=align,
                           leading=leading, leftIndent=left,
                           rightIndent=0, spaceAfter=0, spaceBefore=0)
    return Paragraph(text, style)

def SP(h=1.5):
    return Spacer(1, h * mm)

# ── Page setup ────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT, pagesize=A4,
    leftMargin=9*mm, rightMargin=9*mm,
    topMargin=7*mm, bottomMargin=7*mm
)
W = A4[0] - 18*mm   # usable width  ≈ 174 mm

story = []

# ═══════════════════════════════════════════════════════════
# TITLE BANNER
# ═══════════════════════════════════════════════════════════
title_row = [[
    P("ACUTE SEVERE ASTHMA  —  EMERGENCY QUICK REFERENCE",
      size=13, color=white, bold=True, align=TA_CENTER, leading=16),
    P("Status Asthmaticus  |  GINA / BTS Guidelines",
      size=7.5, color=C_LIGHT_BLUE, align=TA_CENTER, leading=10),
]]
# flatten to 2 paragraphs in 1 cell, 1 column
banner_data = [[
    P("ACUTE SEVERE ASTHMA  —  EMERGENCY QUICK REFERENCE",
      size=13, color=white, bold=True, align=TA_CENTER),
]]
banner_data2 = [[
    P("Status Asthmaticus  |  GINA / BTS / GINA 2024 Guidelines",
      size=7.5, color=C_LIGHT_BLUE, align=TA_CENTER),
]]
for bd in [banner_data, banner_data2]:
    t = Table(bd, colWidths=[W])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), C_DARK_BLUE),
        ("TOPPADDING", (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING", (0,0), (-1,-1), 6),
        ("RIGHTPADDING", (0,0), (-1,-1), 6),
    ]))
    story.append(t)
story.append(SP(2.5))

# ═══════════════════════════════════════════════════════════
# SECTION 1 – SEVERITY CLASSIFICATION
# ═══════════════════════════════════════════════════════════
def sec_hdr(text, bg):
    t = Table([[P(text, size=7.5, color=white, bold=True)]], colWidths=[W])
    t.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg),
        ("TOPPADDING", (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING", (0,0), (-1,-1), 5),
    ]))
    return t

story.append(sec_hdr("▶  SEVERITY CLASSIFICATION (GINA)", C_MID_BLUE))

sev_cw = [W*0.16, W*0.10, W*0.10, W*0.14, W*0.50]
sev_data = [
    # header
    [P("Grade", bold=True, color=white), P("PEF", bold=True, color=white),
     P("SpO₂", bold=True, color=white), P("PaCO₂", bold=True, color=white),
     P("Clinical Features", bold=True, color=white)],
    # rows
    [P("Mild"), P(">80%"), P("≥95%"), P("Low (↓)"),
     P("Mild symptoms; complete sentences; no accessory muscles")],
    [P("Moderate"), P("60–80%"), P("92–95%"), P("Low (↓)"),
     P("Partial sentences; tachycardia; some accessory muscle use")],
    [P("Acute Severe", bold=True), P("<60%", bold=True), P("<92%", bold=True),
     P("Low→Normal", bold=True),
     P("Single words only; tachycardia; accessory muscles; pulsus paradoxus >10 mmHg", bold=True)],
    [P("⚠ LIFE-THREATENING", color=C_RED, bold=True), P("<30%"), P("<92%"),
     P("RISING ⚠", color=C_RED, bold=True),
     P("Silent chest  •  Cyanosis  •  Bradycardia  •  Hypotension  •  Confusion / exhaustion")],
]
sev_t = Table(sev_data, colWidths=sev_cw)
sev_t.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), C_MID_BLUE),
    ("BACKGROUND", (0,3), (-1,3), C_LIGHT_ORG),
    ("BACKGROUND", (0,4), (-1,4), C_LIGHT_RED),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING", (0,0), (-1,-1), 3), ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
]))
story.append(sev_t)
story.append(SP(2.5))

# ═══════════════════════════════════════════════════════════
# SECTION 2 – STEPWISE MANAGEMENT BOXES
# ═══════════════════════════════════════════════════════════
story.append(sec_hdr("▶  STEPWISE MANAGEMENT", C_RED))

steps = [
    ("STEP 1\nOXYGEN", [
        "High-flow O₂ by face mask",
        "Target SpO₂ 94–98%",
        "Continuous SpO₂ monitoring",
        "Hypoxaemia kills – never omit",
    ], C_GREEN),
    ("STEP 2\nSABA", [
        "Salbutamol 2.5–5mg neb (O₂-driven)",
        "OR 4–8 puffs pMDI + spacer",
        "Repeat q20min or continuous",
        "ECG monitor (arrhythmia risk)",
    ], C_MID_BLUE),
    ("STEP 3\nSTEROIDS", [
        "Prednisolone 40–50mg PO OD",
        "OR Methylprednisolone 125mg IV",
        "OR Hydrocortisone 200mg IV",
        "Minimum 5 days; taper if severe",
    ], C_ORANGE),
    ("STEP 4\nADD-ON", [
        "Ipratropium 0.5mg neb q20min×3",
        "IV MgSO₄ 1–2g over 20–30 min",
        "Monitor BP + DTRs during Mg",
        "Consider IV/SC terbutaline",
    ], C_PURPLE),
    ("STEP 5\nBiPAP/ETI", [
        "BiPAP: IPAP 12–18 / EPAP 6–12",
        "RSI: Ketamine 2mg/kg + sux",
        "Vent: TV 6–8mL/kg, RR 10–14",
        "Permissive hypercapnia; low PEEP",
    ], C_DARK_RED),
]

# Header row
hdr_row = [P(s[0], size=7, color=white, bold=True, align=TA_CENTER) for s in steps]
# Body rows (each step has 4 body lines)
body_rows = []
for line_i in range(4):
    row = []
    for s in steps:
        row.append(P(s[1][line_i], size=6.2, align=TA_CENTER))
    body_rows.append(row)

step_data = [hdr_row] + body_rows
step_t = Table(step_data, colWidths=[W/5]*5)
step_styles = [
    ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING", (0,0), (-1,-1), 3), ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    ("GRID", (0,0), (-1,-1), 0.5, white),
    ("BACKGROUND", (0,1), (-1,-1), C_GRAY_BG),
    ("LINEBELOW", (0, len(step_data)-1), (-1, len(step_data)-1), 0.5, HexColor("#BDC3C7")),
]
for i, s in enumerate(steps):
    step_styles.append(("BACKGROUND", (i,0), (i,0), s[2]))
step_t.setStyle(TableStyle(step_styles))
story.append(step_t)
story.append(SP(2.5))

# ═══════════════════════════════════════════════════════════
# SECTION 3 – DRUG TABLE
# ═══════════════════════════════════════════════════════════
story.append(sec_hdr("▶  KEY DRUGS AT A GLANCE", C_TEAL))

drug_cw = [W*0.21, W*0.11, W*0.32, W*0.36]
drug_data = [
    [P("Drug", bold=True, color=white), P("Route", bold=True, color=white),
     P("Dose", bold=True, color=white), P("Notes", bold=True, color=white)],
    [P("Salbutamol (SABA)", bold=True), P("Neb / pMDI"),
     P("2.5–5mg neb OR 4–8 puffs; repeat q20min"),
     P("1st line; O₂-driven nebulisation preferred")],
    [P("Salbutamol IV"), P("IV infusion"),
     P("250mcg slow IV bolus; then 3–20 mcg/min"),
     P("Use if inhaled route unreliable")],
    [P("Ipratropium"), P("Neb"),
     P("0.5mg q20min × 3 doses, then q4–6h"),
     P("Add-on anticholinergic; do not use alone")],
    [P("Prednisolone"), P("PO"),
     P("40–50mg OD × ≥5 days; taper 2 wks if severe"),
     P("Start early; never bronchodilator alone")],
    [P("Methylprednisolone"), P("IV"),
     P("125mg stat; then 40–80mg q6h"),
     P("When PO not tolerated")],
    [P("Magnesium sulfate"), P("IV"),
     P("1–2g IV over 20–30 min (single dose)"),
     P("Life-threatening or poor SABA response; monitor BP + DTRs")],
    [P("Ketamine (RSI)"), P("IV"),
     P("2 mg/kg induction"),
     P("Bronchodilator; preferred induction agent for asthma RSI")],
    [P("Aminophylline"), P("IV"),
     P("5mg/kg load over 20 min then 0.5mg/kg/h"),
     P("⚠ Narrow therapeutic index; monitor levels; last resort")],
]
drug_t = Table(drug_data, colWidths=drug_cw)
drug_t.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,0), C_TEAL),
    ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, C_LIGHT_GRN]),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDC3C7")),
    ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2),
    ("LEFTPADDING", (0,0), (-1,-1), 3), ("RIGHTPADDING", (0,0), (-1,-1), 3),
    ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
]))
story.append(drug_t)
story.append(SP(2.5))

# ═══════════════════════════════════════════════════════════
# SECTION 4 – Bottom 3 columns: Ventilation | Disposition | Warnings
# ═══════════════════════════════════════════════════════════
c1w = W * 0.34
c2w = W * 0.34
c3w = W * 0.32

def mini_section(title, bg, lines):
    """Build a bordered box with a coloured header and body lines."""
    rows = [[P(title, size=6.8, color=white, bold=True)]]
    for item in lines:
        if item == "---":
            rows.append([SP(0.8)])
        elif item.startswith("##"):
            rows.append([P(item[2:].strip(), size=6.5, bold=True, color=C_DARK_GRAY)])
        elif item.startswith("!"):
            rows.append([P(item[1:].strip(), size=6.5, bold=True, color=C_RED)])
        else:
            rows.append([P(item, size=6.3)])
    t = Table(rows)
    t_styles = [
        ("BACKGROUND", (0,0), (0,0), bg),
        ("BACKGROUND", (0,1), (-1,-1), C_GRAY_BG),
        ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2),
        ("LEFTPADDING", (0,0), (-1,-1), 4), ("RIGHTPADDING", (0,0), (-1,-1), 4),
        ("BOX", (0,0), (-1,-1), 0.5, HexColor("#BDC3C7")),
        ("LINEBELOW", (0,0), (0,0), 0.5, HexColor("#BDC3C7")),
    ]
    t.setStyle(TableStyle(t_styles))
    return t

vent_box = mini_section("VENTILATION — BiPAP / ETI", C_DARK_BLUE, [
    "## BiPAP (try before intubation):",
    "• IPAP 12–18  /  EPAP 6–12 cmH₂O",
    "• Neb meds via BiPAP circuit",
    "• Sedation: midazolam 0.05–0.1mg/kg",
    "  OR ketamine 0.5–1mg/kg IV",
    "---",
    "## Intubate when:",
    "• Deteriorating PEF / SpO₂",
    "• Rising PaCO₂ or exhaustion",
    "• Altered consciousness / arrest",
    "---",
    "## Ventilator strategy:",
    "• TV 6–8mL/kg  |  RR 10–14/min",
    "• Long expiry (I:E ≥ 1:3)",
    "• Low PEEP; accept high PaCO₂",
    "• USS: rule out pneumothorax",
    "• ECMO if all else fails",
])

disp_box = mini_section("DISPOSITION FROM ED", C_TEAL, [
    "## Discharge (PEF ≥60%):",
    "• SABA 2–6 puffs q4h till resolved",
    "• Prednisolone 40mg OD × 5 days",
    "• ICS prescribed / reviewed",
    "• Written asthma action plan",
    "• Follow-up within 7 days",
    "---",
    "## Observation/Ward (PEF 40–60%):",
    "• Assess risk factors before discharge",
    "---",
    "## ICU (PEF <40%):",
    "• Life-threatening features",
    "• Needs/near ventilation",
    "---",
    "## Admit risk factors:",
    "• Prior intubation / ICU",
    "• RR >22; SpO₂ <95% on arrival",
    "• >8 SABA puffs in last 24h",
    "• Prior OCS use",
])

warn_box = mini_section("⚠  WARNINGS & KEY POINTS", C_RED, [
    "! NEVER give:",
    "✗  Sedatives — suppress ventilation",
    "✗  Antibiotics (no pneumonia evidence)",
    "✗  Bronchodilators alone — always add CS",
    "---",
    "## Remember:",
    "★ Silent chest = near-complete obstruction",
    "★ Normal PaCO₂ in breathless pt = DANGER",
    "★ Rising PaCO₂ = impending arrest",
    "★ SpO₂ 94–98% — hypoxaemia kills",
    "---",
    "## Monitor:",
    "• Continuous SpO₂ + ECG",
    "• Serial PEF q20–30 min",
    "• ABG if life-threatening",
    "• BP + DTRs during MgSO₄",
    "---",
    "## CXR — only if:",
    "• Suspected pneumothorax",
    "• Consolidation / no Rx response",
])

bottom_t = Table([[vent_box, disp_box, warn_box]], colWidths=[c1w, c2w, c3w])
bottom_t.setStyle(TableStyle([
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    ("LEFTPADDING", (0,0), (-1,-1), 2),
    ("RIGHTPADDING", (0,0), (-1,-1), 2),
    ("TOPPADDING", (0,0), (-1,-1), 0),
    ("BOTTOMPADDING", (0,0), (-1,-1), 0),
]))
story.append(bottom_t)
story.append(SP(2))

# ═══════════════════════════════════════════════════════════
# FOOTER
# ═══════════════════════════════════════════════════════════
footer_t = Table([[
    P("Sources: Fishman's Pulmonary Diseases & Disorders  |  Tintinalli's Emergency Medicine  |  Rosen's Emergency Medicine",
      size=5.5, color=C_MID_GRAY, italic=True),
    P("For use under licensed physician supervision. Not a substitute for clinical judgement.",
      size=5.5, color=C_RED, italic=True, align=TA_CENTER),
]], colWidths=[W*0.6, W*0.4])
footer_t.setStyle(TableStyle([
    ("BACKGROUND", (0,0), (-1,-1), C_LIGHT_BLUE),
    ("TOPPADDING", (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("RIGHTPADDING", (0,0), (-1,-1), 5),
    ("BOX", (0,0), (-1,-1), 0.4, C_MID_BLUE),
]))
story.append(footer_t)

doc.build(story)
print(f"SUCCESS: {OUTPUT}")

Running Command

python3 /tmp/workspace/asthma-pdf/build_pdf.py

The PDF was generated successfully. Here's your one-page quick reference:

Acute Severe Asthma QuickRef

PDF Document · PDF

What's included on the single A4 page:

Section	Content
Severity Classification	Color-coded table (Mild → Life-threatening) with PEF, SpO₂, PaCO₂, and clinical features
Stepwise Management	5 color-coded step boxes: Oxygen → SABA → Steroids → Add-on (Ipratropium + MgSO₄) → BiPAP/ETI
Key Drugs at a Glance	Drug, route, dose, and notes for all 9 agents including salbutamol, ipratropium, Mg, ketamine, aminophylline
Ventilation	BiPAP settings, intubation triggers, permissive hypercapnia strategy, ECMO note
Disposition	PEF-based discharge/admit/ICU criteria with risk factor checklist
Warnings & Key Points	NEVER give list, red-flag reminders (silent chest, rising PaCO₂), monitoring checklist

Sources: Fishman's Pulmonary Diseases, Tintinalli's Emergency Medicine, Rosen's Emergency Medicine.

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