EMCrit Podcast 15 – the Severe Asthmatic

Don’t intubate the severe asthmatic,

try NIV first

continue the nebs on the NIV

obviously they need steroids and throw in Mag Update: (3 MG RCT tells us to skip the Magnesium even in severe asthma)

does ketamine work? maybe…

If you intubate, Ron Walls says add lidocaine to your sedative and paralytic

if you put them on the vent make sure your plateau pressure stays below 30 cm H20

or make sure the flow graph shows flow has stopped before the next breath


Here is the vent lecture:

Not the Greatest Vent Lecture Ever

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  1. says

    Nice discussion as always Scott,

    I like your comments on “To PEEP or not to PEEP, that is the question…” and the difference between peak pressure (what the airway ‘sees’) and plateau pressure (what the alveoli ‘see’ – and what makes them ‘pop’). An ‘expiratory pause’ can also be used of course to quantitate autoPEEP.

    I don’t see as much severe asthma in Australia as back in New Zealand – but IV salbutamol is widely used (esp in NZ) with great anecdotal success ( prior to NIV). Do you use the IV route much in the US?

    All the best,
    Chris Nickson
    ED/ICU Registrar, Perth WA

    • emcrit says


      Unfortunately, it is not available in the US. Only choices for IV meds would be epinephrine or terbutaline. Thanks for the comments.


  2. Kevin says


    As usual, another great job. In the asthmatic population that appears to “failing” NIV with continuous B-agonists (or at least not turning around as quickly you would like) what are your thoughts on IV epinephrine. If you do believe it plays a role in the critical asthma patient what would be your recommendation on dosage? I’ve heard it toted as a viable treatment option by Dr. Herbert from LAC+USC in this situation. Would you use a similar “mix” as you mentioned in you bolus-able pressors talk (1ml of 1:10,000 epi mixed with an additional 9ml of NS)?


    • emcrit says

      Hi Kev,

      I’d probably start with IM dose 0.3 – 0.5 mg 1:1000 as it has the longest track record for use in these patients. If you were to give it IV the 5-20 mcg/5 minutes dose we use for bolus dose pressors would probably work well.


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