Management of acute asthma in ICU

Dr.Zeeshan Waheed
INTRODUCTION

Intensive therapy with inhaled bronchodilators and systemic
corticosteroids is usually sufficient to reduce airflow obstruction and
ameliorate symptoms in patients with acute asthma.

However, some patients develop respiratory failure and require
supportive care with mechanical ventilation (approximately 4 percent of
all patients hospitalized for acute asthma) [1].


Although life-saving, mechanical ventilation and its associated
interventions (eg, sedatives, paralytics) can also cause morbidity and
mortality


Krishnan V, Diette GB, Rand CS, et al. Mortality in patients hospitalized for asthma exacerbations in the United
States. Am J Respir Crit Care Med 2006; 174:633.
Suitable candidates for trial of noninvasive ventilation in acute Asthma*
Clinical observations indicating probable need for elective intubation and mechanical
ventilation in acute asthma*.
Indications for transferring a patient with acute asthma to a closely monitored setting or
intensive care unit*.
Potential reasons for death from acute asthma.
Principles of initial mechanical ventilation for acute, potentially fatal asthma.
n
Ventilator settings

The following are reasonable initial ventilator settings

Respiratory rate 10 to 14 breaths/min
Tidal volume less than 8 mL/kg
Minute ventilation less than 115 mL/kg
Inspiratory flow of 80 to 100 L/min
Extrinsic positive end-expiratory pressure (extrinsic PEEP) less than 80
percent of the intrinsic PEEP



ADVERSE EFFECTS

1. Sequelae of dynamic hyperinflation
Cardiovascular collapse
Barotrauma
Increased work of breathing

2. VAP/Nosocomial Infection









Dynamic hyperinflation in status asthmaticus
Patients with airway obstruction due to obstructive lung disorders, such as
status asthmaticus, expiration time (te) is increased and the lungs take longer
to reach FRC.
In patients with obstructive lung disorders, the lung volume at end-
inspiration (V
EI
) can progressively rise when ventilatory straregies increase
inspiratory time (ti) (eg, generous tidal volumes (V
T
), low inspiratory flow
rates) or shorten te (eg, higher respiratory rates), a phenomenon known as
dynamic hyperinflation.
The volume of trapped air (V
trapped
) above FRC rises at end expiration during
dyanamic hyperinflation.
Dynamic hyperinflation creates intrinsic PEEP and elevates the
plateau pressure (Pplat), which can lead to cardiovascular collapse
and barotrauma, as well as increase the work of breathing.

Adjustments of the ventilator settings should try to minimize the risk
of these events, preferably maintaining an inspiratory Pplat less than
30 cm H
2
O and an intrinsic PEEP less than 10 to 15 cm H
2
O.

The following adjustments may help achieve these goals by
decreasing air trapping :

Increasing the inspiratory flow will shorten the inspiratory time,
increase the expiratory time, and allow the patient more time to
exhale
Decreasing the tidal volume causes less lung inflation and gives
the patient a smaller volume to exhale before the next breath
Decreasing the respiratory rate increases the expiratory time and
allows the patient more time to exhale

Brenner B, Corbridge T, Kazzi A. Intubation and mechanical ventilation of the asthmatic patient in
respiratory failure. J Allergy Clin Immunol 2009; 124:S19.
Additional considerations

Intrinsic PEEP The amount of intrinsic PEEP can be difficult to
measure accurately. As an example, widespread airway closure in patients
with severe asthma may impede measurement of end-expiratory alveolar
pressure, resulting in a falsely low intrinsic PEEP measurement . As a
consequence, marked hyperinflation may be unrecognized.

Asynchrony Even after sedation, some patients are unable to breathe in
synchrony with the ventilator. Paralytic agents may be necessary in this
setting. Adequate sedation must be maintained if paralysis is used [8].
Neuromuscular blockade in patients receiving high-dose corticosteroids
increases the risk of post-paralytic myopathy.

Upper airway obstruction Patients with status asthmaticus typically
have increased airway pressures. Upper airway obstruction should be
considered if a patient presumed to have status asthmaticus does not have
elevated airway pressures. Rarely, upper airway obstruction (eg, vocal cord
dysfunction, laryngeal malignancy) can mimic status asthmaticus.
ADJUNCTIVE THERAPY

General anesthesia Induction of general anesthesia, either by
intravenous infusion (eg, ketamine) or inhalation (eg, isoflurane), can
reduce bronchospasm. This approach should not be undertaken lightly,
due to the risk of profound hypotension . An anesthesiologist is required
for the duration of the anesthesia and bronchoconstriction generally recurs
when anesthesia is withdrawn. The duration of general anesthesia
typically ranges from 2 to 12 hours.

Heliox Heliox is a blend of helium and oxygen that has a lower density
than air. Heliox can reduce resistance to airflow, enhance delivery of
nebulized bronchodilators, and improve oxygenation compared to
standard nitrogen-oxygen mixtures. However, it can also cause ventilator
malfunction, including inaccurate measurement of tidal volume and
oxygen concentration.

Extracorporeal life support Oxygenation and carbon dioxide removal
through an artificial membrane may be beneficial for patients with status
asthmaticus complicated by refractory respiratory acidosis, although
clinical outcome studies are lacking

Key messages for the management of assisted ventilation for acute, potentially fatal asthma*.
PROGNOSIS
Patients with status asthmaticus who require mechanical
ventilation have increased in-hospital mortality compared to
patients who do not require mechanical ventilation (7 versus 0.2
percent) .

Patients who survive to hospital discharge remain at high risk of
death; this excess risk is only beginning to be recognized and may
be worse than some malignancies. As an example, one study
assessed the outcome of 145 survivors of status asthmaticus who
required mechanical ventilation for a duration of six years [2].

The one-, three-, and six-year mortality rates were 10, 14, and 23
percent, respectively. Most of the deaths were due to recurrent
asthma.



Marquette CH, Saulnier F, Leroy O, et al. Long-term prognosis of near-fatal asthma. A 6-year follow-up
study of 145 asthmatic patients who underwent mechanical ventilation for a near-fatal attack of asthma. Am
Rev Respir Dis 1992; 146:76.