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Definition
Asthma: Diffuse pulmonary disease
characterized by hyper-reactivity of trachea
and bronchi, causing generalized narrowing
of the airway in response to certain
nonspecific stimuli.
Status asthmaticus: Life threatening form of
asthma characterized by unresponsiveness
to the usual adrenergic drugs, resulting in
respiratory failure.
STATUS ASTHMATICUS:
Asthma attack refractory to initial therapy
Wheezing
Tachypnea
Retractions
Nasal flaring
Use of accessory
muscles
Cough
Anxiety
Dehydration
Tachycardia
Late bradypnea
Oxygen
Beta2-agonist bronchodilator
Consider steroids
Medications
Consider mechanical ventilation
Wheeze
< 30
< 20
None
No apparent activity
31-45
21-35
Terminal expiration
heard with
stethoscope
Questionable increase
46-60
36-50
Entire expiration
heard by
stethoscope
Increase apparent
> 60
> 50
inspiration and
expiration
without stethoscope
Maximal activity
Breathlessness
PaCO2
normal or increased
PEFR
Pulse
Tachycardia
Expert Panel Report 2: Guidelines for the diagnosis and management of asthma.
National Institute of Health- National Heart, Lung and Blood Institute 1997; NIH
publication number 97-4051
bronchoconstriction
Treat airway inflammation
Correct hypoxemia
Consider differential
diagnosis
Monitor for complications
Pneumothorax
Hypotension
should beta-agonists be
administered?
Do anti-cholinergics have a role?
Does aminophylline have a role?
Does magnesium have a role?
Should heliox be used?
Does ketamine have a role?
Should non-invasive ventilation be used?
What should the ventilator settings be if
the patient is intubated?
SC
A randomized
Continuous
Small
125 mg IV methylprednisolone
40-60 mg PO prednisone
(2 mg/kg)
No
muscle relaxation
(bronchodilation)
2 gm of MgSO4 is safe and beneficial
in patients with severe acute asthma
exacerbations (FEV1<25% predicted)
Rowe. Magnesium sulfate for treating exacerbations of
acute asthma in the emergency room (Cochrane Review)
The Cochrane Library. Issue 3, 2003.
25-50
mg/kg max 2 gm
What is heliox?
Helium/Oxygen
Laminar
mixture
inspiration
Reduced
work of breathing
Heliox-driven
should be based on
clinical deterioration (altered mental
status, respiratory fatigue)
Neither
Do
Lidocaine
Glycopyrollate or atropine
Induction
with ketamine
Paralysis
with succinylcholine
Intubation
Mechanical Ventilation in
Asthma
Volume
cycled ventilation
FiO2
1.0
Rate
8-10
I:E 1:4 or 1:5
VT 5-7 cc/kg
PEEP 0
Maintain
peak pressures < 45 cm H20,
plateau pressure < 30 cm H20
for pneumothorax
Consider
pressure-controlled
ventilation
Complications of Mechanical
Ventilation
Hypotension
Barotrauma
Post-arrest with or
without intubation
Failure to improve after
intensive ED Rx
Air leak syndrome
Clinical dehydration or
risk of dehydration
Altered
LOC
Exhaustion
Deteriorating patient
Drug toxicity
Silent chest
CONCLUSIONS
Beta-agonists