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Mechanical Ventilation for Severe Asthma

Fortunately, most often the patient with severe Status Asthmaticus can be managed without intubating... If you have been placed between the rock and the hard place, and now must use mechanical ventilation, consider the following: Use a Cuffed Endotracheal Tube! Initial Ventilator Settings (Oddo, 2006): Mode: there is no evidence to support one mode over another. Many start with Volume-Control. Tidal Volume: 6-10 ml/kg ideal body weight. Enough to move the chest. Expiratory Time: 4-5 seconds. Inspiratory:Expiratory ratio may be 1:4, but can be as high as 1:8. Goal is to allow exhalation and avoid stacking breaths with barotrauma.

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 Management of Acute Pediatric Asthma Exacerbations

The decision to intubate should be based on clinical judgement as opposed to any single vital sign or blood gas result. Some variables to consider for intubation are worsening hypercapnea, patient exhaustion and changes in mental status.

Articles of Interest

Emergent Management of Pediatric Asthma: Myths & Pitfalls

• Get steroids onboard early – Decadron = Prednisone • Duoneb x 3 in first hour • MDI-Spacer = Nebulizer • Advance therapies (continuous, magnesium, parental beta-agonist) • Avoid pitfalls (V/Q mismatch, lactic acidosis, IVF)

Hydration and Status Asthmaticus

We are all proficient at the management of asthma exacerbations. Regardless of the season, there are always innumerable triggers of reactive airway disease and, hence, we have become very adept at its management. Certainly, though, it can still generate significant morbidity and mortality and should never be taken lightly {remember to be ever vigilant, even when very comfortable}. Additionally, there can still be some questions about the management of these patients – particularly, the very sick ones.

NIV for status asthmaticus

Although there is some evidence for the use of NIV in status asthmaticus, there are few randomised control trials.

Noninvasive Ventilation in Pediatric Status Asthmaticus is Often Initiated in the ED

The study authors concluded, “NIV was frequently used, well tolerated, safe, and few patients progressed to mechanical ventilation.”

Pediatric Asthma Exacerbation

Critically ill pediatric patients are anxiety provoking for many emergency medicine providers and simulation can help prepare individual providers, enhance team dynamics and test clinical systems. This cases pushes participants to the furthest reach of asthma treatment for a young, vulnerable patient.

Status Asthmaticus in the Pediatric ICU: A Comprehensive Review of Management and Challenges

Noninvasive ventilation, such as high flow nasal cannula (HFNC), continuous positive airway pressure (C-PAP), and bilevel positive airway pressure (BiPAP), can be trialed in status asthmaticus. Continuous positive airway pressure, as seen in HFNC and C-PAP, is thought to stent open small airways and allow better penetration of bronchodilators to small airways.

Steroid Selection In Pediatric Asthma

Perhaps, the real take away message should be that any difference between different corticosteroids is likely negligible. Nevertheless sufficient evidence exists to suggest using dexamethasone for immunocompetent pediatric asthma patients who may be discharged home or admitted in a non-ICU setting. The current literature suggests that IM and PO are equally efficacious, so a conservative approach with 0.6mg/kg PO or IM initially and then a second dose PO, would likely be acceptable to most practicing emergency physicians and would have the added benefit of still dispensing a single, potentially therapeutic dose in the ED in the event the second dose is not taken.

The Pediatric Respiratory Score

The score is made up of four categories that are evaluated with a score of 0-3. While the table is large, most of it is composed of specific respiratory rate cut-offs. It is designed to be user friendly, but not something to commit to memory.

Resources

Critical Care Clinics

Status asthmaticus is a major cause of acute illness in children and one of the top indications for admission to a pediatric intensive care unit (ICU).1–5 Mortality is rare after a child arrives at medical attention, but morbidity can be high with some children requiring days or weeks of hospitalization and recovery.

LearnPICU

Intubation occurs in a small number of asthmatic patients admitted to the PICU (4-10% with significant variability). No clear indications and largely based on clinical judgment.