Directed physical examination reveals hyperresonance to percussion, decreased intensity of breath sounds, and prolongation of the expiratory phase, usually with wheezing. Although wheezing results from the movement of air through narrowed airways, the intensity of the wheeze may not correlate with the severity of airflow obstruction. The "silent chest" reflects very severe airflow obstruction, with air movement insufficient to promote a wheeze. A pulsus paradoxus above 20 mmHg is also indicative of severe asthma. Although tachycardia and tachypnea are usually seen with acute asthma, vital signs normalize very quickly as airflow obstruction is relieved. Therefore, a normal heart rate, respiratory rate, and the absence of a pulsus paradoxus do not indicate complete relief of airway obstruction.
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