Asthma

Decompensation: noncompliance, URI, viruses, pneumonia, med changes, heroin, cocaine

Treatment

MgSO4 in severe attack, it only helps in FEV1<25% predicted (CHEST 2002; 122:489–497)

Proventil

Nebulized B-Agonists will lower your potassium, magnesium, and phosphate (Annals of EM 21:11, 1992) and

Cydulka RK et al:
Comparison of single 7.5-mg dose treatment vs sequential multidose 2.5-mg treatments with nebulized albuterol in the
treatment of acute asthma. Chest 122:1982, 2002 can give 7.5 over 1 hour, much easier

In adults, no difference between normal and Lev albuterol (The American Journal of Emergency Medicine
Volume 24, Issue 3 , May 2006, Pages 259-267)

Atrovent

Do not give atrovent or combivent inhalers to patients with peanut allergies as contain soy lecithin which cross reacts with peanut allergies in ~10% of cases. Nebs are not a problem.

Give 3 doses of 0.5 mg Q 20 min then as needed in the ED, not in the hospital (National Asthma Ed and Prevention Program Guidelines 2007)

Epinephrine

Epi .3-.5 mg SQ q 10 (Actually better to go into thigh IM Journal of Allergy and Clinical Immunology 108:5 2001)

same cardiac side effects between terbutaline and epinephrine (Chest 1975 67:279)

Terbutaline

Longer lasting than epi, but much slower onset. Use epi for first dose then switch to terbutaline. (ACLS EP)

Aminophylline

Nebulized Magnesium

The intervention involved administering a single dose of 2.5 mg (0.5 cc) of albuterol mixed with 2.5 cc of normal saline (A+S group) or 2.5 mg (0.5 cc) of albuterol mixed with 2.5 cc of isotonic magnesium sulfate (A+M group). Magnesium was supplied in the form of 6.3% solution of magnesium heptahydrate, which is equivalent to 3.18% anhydrous magnesium sulfate. These were nebulized with 8–10 L/min of oxygen. The study medications were provided in identical syringes and both the pharmacy and the investigator were blinded to their contents. All patients received 2 mg/kg of prednisone for asthma after their first dose of inhalation medication. (JEM July 2004 )

can give one single IM injectionsof 160-mg methylprednisolone acetate (depo-medrol) and will equal efficacy of course of oral steroids (Chest 2004 AugChest 2004;126:362-8.)

Nebulized Lasix

Severe Asthma

RSI

Drugs

Terbutaline Drip-4 mcg/kg over 10 minutes followed by .04 to .2 mcg/kg/min (250 mcg over 10 minutes then 3-12 mcg/min)

Aminophylline 5 to 6 mg/kg over 20 minutes, followed by a maintenance infusion of .6 to .9 mg/kg/ hour (Not really done anymore)

Ketamine Bolus 1.5 mg/kg then if needed repeat at 2 mg/kg or Infusion .5-2 mg/kg/hr

Heliox beneficial if high pressures in vented patients (Am J Resp Crit Care Med 165:1317, 2002)

Myopathy in asthma patients with non-depol paralytics especially with steroids (Jagoda Asthma Article JB19)

Consider Triple Therapy for Severe Asthma Prospective, Double Blind Add to combivent, flunisolide 1 mg Q10) or use Decadron 4 mg in Neb (Chest 123(6):1908, June 2003)

Isotonic Nebulized Saline resulted in improved FEV1 (Lancet 361:2114 June 21,2003)

Heliox

Heliox for asthma in the emergency department: a review of the literature (Emerg Med J 2004; 21:131-135)

ICU Care

AutoPEEP

consider if the patient is hypotensive after initiation of mechanical ventilation

test by lowering resp rate, occluding exhalation hose, and after patient finishes a breath, observe pressure

NIPPV

IV Contrast

steroids do not help unless given 6-12 hours before study, give 3 doses Q6 of prednisone. Also give benadryl.

risk using low osmolality non-ionic contrast with asthmatic is same as regular contrast with non-asthmatic

Inhaled budesonside: JAMA 281(22):2119, June 9, 1999. Relapse rate of 13% vs. 25%

Inhaled Steroids

1.5 mg/kg (maximum, 45 mg) of nebulized dexamethasone (dexamethasone sodium phosphate, 10 mg/mL; Gensia) (Annals EM 26:485, 1995)

1) Take the PEEP off (show me exactly what it is doing usefully for THIS patient).

2) Decrease the rate a lot (perhaps to 8) with a 20% inspiratory time. Modify the inspiratory flow pattern (take off the "inspiratory rise time" if you are using Servo300 or similar feature in other ventilator).

3) Titrate tidal volume to gas-trapping (expiratory flow graphic sometimes helpful, but the "ear to the tube" method works well for me) -- and be much more relaxed about PIP during periods of high inspiratory resistance (caution when the bronchospasm breaks). See Dave Tuxens papers in the early 1990s -- e.g. Am Rev Respir Dis. 1992 Nov;146(5 Pt 1):1136-42. You might find that with a rate of 8 and an expiratory time of ~ six seconds that you can get VE of around 6 litres with PIP of 40 or leven less and intrinsic PEEP of less than five) and much better alveolar ventilation as Vd/Vt is VERY different.
4) At five days she has probably compensated for the respiratory acidosis but we would sometimes give a little THAM acutely to get pH above about 7.05 (Do bronchodilators work better then?)

5) I bet she has had lots of mineralocorticoid (hydrodrocortisone) and salt water (count up all the saline bags and "diluents" over five days, test the depth of oedema with a thumb "the Bob Wright method" and then a) Stop all saline, b) diurese gently (lots of extra K+< maybe Mg++ too), to "dryness" c) give a salt-free feed, d) change to dexamethasone or at least prednisone if this has not already happened.

6) I usually don't use muscle relaxants after a short time i.e. 12-24 hours of so -- I see if the patient can be managed without them, usually with a combination of fentanyl and diazepam. I like to see the patient doing some expiratory assistance of their own, failing that I might give only a "softening dose" of relaxant (1-2 mg/hr of pancuronium -- cheap, pressor and long acting -- maybe less critical-illness polyneuropathy than vecuronium too). Let the patient help shift secretions by coughing (just a little).

7) We would not see this as "desperate straits" and would not use ketamine, inhalational agents etc in such a patient. Sit tight and avoid complications.

8) Despite all that is written about asthma in less severely ill patients, a trial of theophylline might be useful -- it sometimes is.

9) I agree that we sometimes use IV adrenaline (epi to you Leo) instead of salbutamol (albuterol to you Leo) but both cause lactic acidosis, hypokalaemia, hyperglycaemia and perhaps adrenaline gives you some alpha action which might protect against the theophylline+IPPV hypotension.

10) 1:1 nursing is good -- old nurses are best -- ones who are old enough to have remembered ventilating these patients breath to breath on a Bird MkVII are to be preferred most ..

Inhaled Steroids
Triamcinolone	MDI	2 puffs bid-qid	Rinse mouth after use	$52/ cannister
Beclomethasone	MDI	2 puffs bid-qid	Rinse mouth after use	$52/ cannister
Budesonide	MDI	1-2 puffs bid	Rinse mouth after use	$108/cannister
Fluticasone	MDI, varying strengths	1-2 puffs bid	Rinse mouth after use	$44-$91/cannister