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