Status Asthmaticus

Medical management:
-O2, fluids*
-bronchodilators, magnesium
-heliox if NOT hypoxemic (using heliox means proportionally less FiO2)
-epi IM 0.01 mg/kg OR dirty epi drip
-BiPAP: 10 IPAP / 3-5 PEEP (EPAP) (aka “ZEEP”. When pts begin tiring out, inspiratory pressure support helps move air in and out)

*Note:
-hypoxemia is a LATE finding in asthma – give O2 EARLY to promote pulmonary vasodilation
-“normal” pCO2 on blood gas = pt tiring out (compensating pts will have low pCO2 as they hyperventilate to blow off lactic acid)
-these pts are severely volume-depleted due to insensible losses – need fluids! (30cc/kg)
-lung ultrasound has primarily A lines (no interstitial fluid)
-these pts can tolerate hypercapnea and acidosis

Absolute indications for intubation:
-deteriorating consciousness
-respiratory muscle fatigue nonresponsive to BiPAP
-cardiac/respiratory arrest

Avoid intubation as it does nothing to fix the underlying problem of bronchoconstriction and increases risk of hyperinflation.

Intubation:
-use DSI with ketamine 1-2 mg/kg*. Choose roc for longer paralysis to prevent vent asynchrony
-hyperinflation (due to breath-stacking) is your enemy — increased airway pressures = risk for tension PTX, decreased venous return and thus cardiac output
-strategy = permissive hypercapnea – to allow for full exhalation:
—-RR 6-8 breaths/min, TV 6cc/kg, <5 PEEP, inspir flow rate 100-120 L/min

Subdissociative dose ketamine 0.5-1 mg/kg

The Deteriorating/Coding Intubated Asthmatic:
-disconnect from vent, allow exhalation (may push on chest), and slowly bag at 6 breaths/min
-if no improvement and see breath-stacking on vent, needle decompression / finger thoracostomy
-DOPES: Displaced tube (use VL or bronchoscope to confirm), Obstruction (pass suction catheter, look for kinking of tubing), T-PTX, Equipment problem, Stacked breaths
-VV ECMO

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