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HWN Suggests

The Crashing Asthmatic Patient

I have 2 rules here:

1. Do not intubate, if at all possible. It will be horrific... They can go on for a while, so there is a little bit of time, but only a little bit- so prime your team and go go go! Do not intubate if at all possible.
2. Throw everything you have at the patient. This is the time to go in all guns blazing.

We use my old friend the nasal canula. We put them on under the mask delivering the salbutamol. I turn them up to somewhere above 15L/min, but probably closer to 60L/min. They don’t bother the patient at this point as she is CO2 narcotised. We then run the mask over this at 6L/min and deliver the salbutamol.

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 The Crashing Asthmatic

Sub-dissociative dose IV Ketamine (0.1 mg/kg followed by IV infusion of .5 mg/kg/hour for 3 hours) may be helpful to facilitate use of BiPAP in a hypoxic/combative patient

 The Crashing Asthmatic – Recognition and Management of Life Threatening Asthma

The goal of our interventions is to get the patient out of the “vicious cycle” of severe asthma exacerbations. If tachypnea can be reduced and ventilation improved, the need for intubation can be prevented. In patients who are very tachypneic with severe work of breathing, adjuncts like ketamine or fentanyl can aid in tachypnea reduction and may facilitate improved delivery of bronchodilators/NIPPV.

 Why we do what we do: Treatments for severe asthma

Patients with severe asthma exacerbations will get the proverbial “kitchen sink” thrown at them when it comes to treatment. First of all, that old idiomatic statement posits asthma treatment as a battle*, which it shouldn’t be. But you should be armed with a solid understanding of the evidence behind the treatments that we use when treating patients with this potentially fatal disease.

Articles of Interest

Approach to Asthma in the ED

Heliox: A mixture of helium and oxygen theoretically increases laminar flow in narrow airways and may facilitate gas exchange.

Core EM: Life-Threatening Asthma

Stave off intubation while your medications have time to act. Intubation is associated with increased morbidity and mortality.

Critical Asthma Patient: Pearls/Pitfalls of Management

Pitfalls - Assumption that an asthma patient has asthma (rather than, for example, pneumothorax or pneumonia). Inadequate use of permissive hypercapnia for the ventilated asthmatic. Don't sweat the hypercapnia; trying to bring down the PaCO2 is often more harmful than helpful. Over-bagging of the asthmatic after intubation. This carries a high risk of gas trapping and pneumothorax. It's probably ideal to connect these patients to a ventilator as soon as possible to provide controlled ventilation. Note that “wheeze” or stridor you can hear across the room isn't due to asthma (suggests upper airway obstruction instead).

Emergency management of severe asthma

Quick epinephrine drip: 1 mg of epinephrine in a 1L bag of saline. This results in a concentration of 1mcg/mL. Therefore a 60ml/hr infusion will give you 1 mcg/min

EMU 365: The Crashing Asthmatic

Dr. Mike Betzner takes us through one of his best cases ever with a crashing asthmatic patient and discusses how to respond to the most severe asthma presentations.

Epinephrine/Terbutaline in Acute Asthma Exacerbation

The evidence is limited, but epinephrine and terbutaline are fairly safe, effective, and may be especially useful in sick asthmatics refractory to standard therapies.

Intubating Asthma

If a room full of emergency medicine physicians was asked, “How would you manage a severe asthmatic?” There would be a plethora of responses. However, all would likely agree that intubation is a last resort; something only to be considered when all other treatment options have been exhausted.

Resources

Life in the Fastlane

induction agent: — ketamine preferred due to bronchodilation — propofol is an alternative, but beware hypotension.

the NNT

In summary, for adults presenting to the ED with moderate to severe asthma exacerbations, intravenous magnesium sulfate therapy used as an adjunct to routine treatment (oxygen, short acting beta agonists and systemic corticosteroids) or when these treatments fail, reduces the need for hospitalization and likely has minimal adverse events. Therefore, we have assigned a color recommendation of Green (benefits > harm) to this treatment.

International Emergency Medicine Education Project

Inhaled short-acting beta2-agonists (SABAs): Use 4-10 puffs pMDI with a spacer in mild or moderate attacks. For severe attacks, administer 1 nebule every 20 minutes for 1 hour.