Much of what we learn about asthma is not applicable to the very end-stage just prior to intubation. This period of the disease has a unique pathophysiology. The severe asthmatic needs to be managed in a way that is cognizant of this physiology-and quickly!!!!
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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,… Read more »
Unfortunately, it is not available in the US. Only choices for IV meds would be epinephrine or terbutaline. Thanks for the comments.
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)?
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.
You mention NIPPV prior to intubation. What settings would you suggest?
Update on magnesium: Cochrane reviewed 14 RCT (including 3Mg published in 2013) and based on the pooled data, IV magnesium DOES reduce admission to hospital (7 admissions reduced for every 100 patients treated)…
Read more: http://www.ncbi.nlm.nih.gov/pubmed/24865567
Sanjin, ED Pharmacist
Also, surely this drug is rate dependent not dose. You just have to see the vasodilation! Wouldnt jump to say it doent work off of a self fulfilling prophecy. Need to compare stat dose.
Scott, I continue to be amazed by how great this site is. I always find you to be a wonderful resource…I hope its ok to challenge your advocacy for NIPPV is truly severe status. I think there are probably 3 groups–asthma exacerbation without resp compromise, asthma exacerbation with resp weakness (where NIPPV may have a role with someone who truly knows how to drive NIPPV) which is largely what you described, and life-threatening status. For life threatening status, with short i-time, most of the inspiratory flow will go to the stomach rather than the airways. This will cause severe gastric… Read more »
replied to in the addendum above
Hi Scott, Firstly, love the blog/podcasts, great job! I have a question regarding the use of CPAP for the severe asthmatic. I am an Intensive Care Paramedic working for an Australian Ambulance Service, and our current clinical guidelines recommend the use of either nebulised salbutamol/ipratropium, push-dose IV adrenaline (up to 50mcg per dose) as well as an adrenaline infusion, and IV hydrocortisone, for the treatment of bronchospasm in the prehospital setting. We also have CPAP masks which are recommended at this time only for use in the setting of acute cardiogenic pulmonary oedema. Having listened to your podcast on the… Read more »
there is lit on improvement with CPAP but not as impressive as IPAP. I’d probably stick with regular neb masks in that situation.
thank you, scott.
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