Status Asthmaticus

Aka: Status Asthmaticus

1. See Also
   1. Asthma Exacerbation
   2. Asthma Education
   3. Asthma Management
   4. Asthma Exacerbation Home Management
   5. Emergency Management of Asthma Exacerbation
   6. Asthma Inpatient Management
2. Management: Follow Initial Management per other protocols
   1. See Asthma Exacerbation Management in the ER
   2. See Asthma Inpatient Management
3. Management: Additional Measures for extremis
   1. Nebulized Albuterol with Atrovent hourly or Continuous
   2. Systemic Corticosteroid
   3. Epinephrine 0.01 mg/kg up to 0.3 mg SC
      1. May be repeated every 5 minutes
      2. Terbutaline SQ may be used as an alternative option
   4. Oxygen 100% (warm, humidified) by nonrebreather mask
   5. Two Intravenous Lines
   6. Hypotension
      1. Hypotension is common in severe Asthma (increased thoracic pressure prevents venous return)
      2. Consider fluid bolus of normal saline 10-20 ml/kg IV (to 500 to 1000 ml IV)
      3. Chest XRay to evaluate for Tension Pneumothorax
   7. Consider Magnesium 40-75 mg/kg up to 2 grams IV for 1 dose
      1. Rapidly effective in pediatric Asthma Exacerbations
      2. Also shown effective in severe adult acute Asthma
      3. Some studies question benefit
      4. References
         1. Silverman (2002) Chest 122:489-97
         2. Hughes (2003) Lancet 361:2114-7
   8. Consider Ketamine
      1. May improve Status Asthmaticus (not limited to intubation)
      2. Bolus: 1-2 mg/kg (consider 1 mg/kg to start)
      3. Maintenance: 2-3 mg/kg/hour (consider 0.25 mg/kg/hour to start)
   9. Consider BiPAP
      1. Inspiratory pressure: 12
      2. Expiratory pressure: 6
      3. Consider in combination with Ketamine for Sedation
         1. Use the lower doses listed above (1 mg/kg bolus then 0.25 mg/kg/hour)
   10. Consider Heliox (helium to oxygen 80:20 70:30 or 60:40)
       1. Reduces work of breathing and improves Peak Flow
       2. Risk of Hypoxemia if FIO2 of oxygen in mixture is too low
   11. Avoid Aminophylline or Theophylline
       1. Risk of adverse effects outweigh any marginal benefit
       2. Rare indication may be a patient in such distress that will not tolerate the nebulizer
4. Management: Intubation and Mechanical Ventilation
   1. Precautions: Intubation is best done semi-electively before crisis
      1. Intubation criteria are based on clinical judgment
      2. Best if intubation can be avoided due to high risk of complications in Asthma
   2. Indications (indicated in 0.5% of Asthma Exacerbations)
      1. Impending or actual respiratory arrest
      2. Extreme Fatigue
      3. Altered mental status
      4. Significant respiratory distress
      5. Severe Respiratory Acidosis and Metabolic Acidosis
   3. Oral intubation is preferred
      1. Lower resistance and easier suctioning
      2. Lower Incidence of Sinusitis
   4. Endotracheal Tube selection
      1. Choose largest Endotracheal Tube possible (uncuffed if necessary)
   5. Rapid Sequence Intubation
      1. Sedation: Ketamine is preferred in Asthma Exacerbation
         1. Etomidate can be used as an alternative
      2. Paralytic
         1. Succinylcholine (preferred due to shorter duration)
         2. Rocuronium (if Hyperkalemia risk)
      3. Consider Lidocaine for pretreatment
      4. Consider normal saline bolus (10-20 cc/kg) to prevent post-intubation Hypotension
      5. Maximize preoxygenation (see Rapid Sequence Intubation for protocol)
   6. Post-intubation management
      1. Avoid repeated Paralytic Agents after intubation if possible
      2. Continue aggressive Asthma Management after intubation
         1. Duonebs
         2. Magnesium
         3. Corticosteroids
      3. Ketamine may be preferred for post-intubation (Bronchodilator and mucolytic)
         1. See doses above
      4. Permissive hypercapnea (allowing CO2 to rise)
         1. Preferred over aggressive Hyperventilation with risk of barotrauma (Pneumothorax risk)
         2. Settings to prevent baratrauma
            1. Ventilator rate: Low
            2. Tidal Volume: Low
            3. Flow rate: High
            4. E-Time: high
            5. Consider PEEP 3-5
               1. Requires close observation for auto-PEEP by patient
      5. Difficult to ventilate patients
         1. May benefit from inhalation gasses in operating room or ECMO
5. Management: Cardiac Arrest
   1. Disconnect the Ventilator
      1. Manually ventilate slowly
      2. Prevents breath stacking
   2. Decompress the chest manually
      1. Bear hug to remove trapped air
   3. Place bilateral Chest Tubes
      1. High risk of Tension Pneumothorax
      2. May temporize with bilateral needle thoracostamy
   4. Empirically give intravenous fluids (1 Liter)
      1. See Hypotension above
6. References
   1. Majoewsky (2012) EM:RAP-C3 2(2): 1
   2. (1997) Management of Asthma, NIH 97-4053
   3. (1995) Global Strategy for Asthma, NIH 95-3659
   4. Pollart (2011) Am Fam Physician 84(1): 40-7
   5. Ciarallo (2000) Arch Pediatr Adolesc Med 154:979-83
   6. Sarfone (2000) Ann Emerg Med 36:572-8