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Status Asthmaticus

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Status Asthmaticus Rich Kaplan MD, MS, FACEP Case #1 18 y.o. old BM 1-2 word dyspnea Severe distress No history of intubation Denies drugs Case #1 PHx Asthma ... – PowerPoint PPT presentation

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Title: Status Asthmaticus


1
Status Asthmaticus
  • Rich Kaplan MD, MS, FACEP

2
Case 1
  • 18 y.o. old BM
  • 1-2 word dyspnea
  • Severe distress
  • No history of intubation
  • Denies drugs

3
Case 1
  • PHx
  • Asthma
  • Allergies
  • Meds
  • Advair
  • Singulair
  • Albuterol inhaler
  • Duonebs
  • Uses less than once a week

4
Case 1
  • HR 140s
  • RR 40s
  • BP stable
  • No room air sat
  • He is above 90 on nebs

5
Case 1
  • Severe dyspnea
  • May need to be intubated
  • Protecting his airway
  • Looks tired
  • Marked accessory use
  • Not much air movement

6
Case 1
  • Your exam should take seconds
  • You cannot access anything from sunrise
  • What do you do now?

7
Case 1 Immediate Treatment
  • Albuterol
  • Atrovent
  • Solumedrol
  • Terbutaline
  • MgSO4

8
Case 1
  • Still with severe distress
  • 2 word dyspnea
  • Looks tired
  • Intubation equipment at bedside

9
Case 1 More Treatment
  • BIPAP
  • Heliox ( 7030)
  • Epinephrine Drip
  • 1mg Epi/ 250cc bag ( 4 mcg/cc)
  • Consider starting at 4 mcg/min

10
Case 1
  • He seems to be doing better with
  • BIPAP
  • Heliox
  • Epi drip
  • Still has impressive inspiratory and expiratory
    wheezes
  • Limited lung expansion after about 15 minutes

11
Case 1
  • It is ICU time
  • Now we need an ABG
  • CO2 is 50.8
  • ICU attending will only accept the patient if he
    is intubated
  • He will not accept BIPAP
  • BIPAP discontinued
  • ED attending tells ICU attending that ABG will be
    repeated after 30 minutes on Face mask
  • Epi drip is increased to 8mcg/min
  • HR is less than 100
  • RR in the 20s

12
Case 1
  • Meanwhile How does the patient look???
  • Still has impressive inspiratory and expiratory
    wheezes
  • Increased lung expansion
  • Speaking about 5 words at a time
  • Playing with his cell phone
  • Family is present in the room

13
Case 1
  • Patient instructed to try to take deep breaths
  • His respiratory rate is now about 16
  • He is on Face mask with heliox ( 7030)
  • Epi drip has been increased to 8 mcg/min
  • Patient is told that if he breathes better and if
    his repeat ABG is improved, that he will not
    require intubation

14
Case 1
  • Repeat CO2 in about 30 minutes is 33
  • Patient has improved markedly
  • Patient is now Denied admission to ICU

15
Case Summary
  • Multiple scenarios with similar presentation and
    outcome
  • Avoided intubation
  • Status asthmaticus
  • 1-2 word dyspnea
  • Multiple breathing treatments
  • Terbutaline
  • Heliox
  • BIPAP
  • IV Epi

16
Status Asthmaticus
  • Treatment
  • Albuterol
  • Atrovent
  • Steroid
  • Terbutaline
  • Epinephrine
  • Heliox
  • BIPAP
  • Intubation
  • Ketamine
  • Inhalational anesthetics
  • Extracorporeal life support

17
Status Asthmaticus
  • Severe bronchospasm that does not respond to
    aggressive therapies within 30-60 minutes
  • Severe asthmatic attack with one or more of the
    following
  • Dyspnea (precluding speech), accessory muscle
    use, RR 35/min
  • Hr gt 140/min
  • Peak expiratory flow lt 100 l/min
  • I do not measure Peak flows
  • Hypercapnea ( gt 50 mmHg)

18
Acute Severe Asthma
  • Critical limitation of expiratory flow
  • Increased airway resistance
  • Premature airway closure
  • Lung and chest wall dynamic hyperinflation
  • High intrinsic PEEP
  • Respiratory muscle fatigue

19
Near-Fatal Asthma
  • Respiratory arrest or respiratory failure (PCO2 gt
    50 mmHg)

20
Fatal Asthma
  • Slow-onset
  • Gradual deterioration of asthma symptoms over
    several days
  • Usually associated with chronic poorly controlled
    asthma
  • Eosinophilic predominance and mucus in submucosa
  • Rapid-onset
  • Symptom onset and progression to life-threatening
    status within 3 hours
  • Greater hypercapnea
  • Neutrophilic predominance in airway submucosa

21
The Four Compartments
o
o
22
Respiratory Mechanics
  • The lung is not homogenous during acute severe
    asthma
  • Driving force for expiratory flow is decreased
  • Persistent activation of inspiratory muscles
    during expiration---
  • Abnormal low pulmonary elastic recoil
  • High outward recoil of chest wall
  • Resistance to airflow strongly increased

23
Respiratory Mechanics
  • Markedly prolonged expiration
  • Inspiration starts before static equilibrium is
    reached
  • Positive End-Expiratory alveolar Pressure
  • Auto-PEEP (intrinsic PEEP, PEEPi)

24
Dynamic Hyperinflation
  • Incomplete alveolar emptying at
  • the end of expiration
  • Intrinsic PEEP
  • Measure end-expiratory flow or
  • End-expiratory pressure
  • Increased ventilatory requirement
  • Prolonged expiratory time
  • Increased inspiratory threshold load

25
Dynamic Hyperinflation
  • Shortening of
  • Diaphragm
  • Inspiratory intercostals
  • Accessory muscles
  • Decreased mechanical efficiency
  • Increased risk of fatigue
  • With increased obstruction
  • CO2 production gt Elimination by alveolar
    ventilation
  • CO2 increases

26
Dynamic Hyperinflation
  • Mean pleural pressure becomes more negative
  • Interstitial pressures are also lowered
  • Vascular pressure is maintained
  • The result
  • Interstitial edema and further increase in
    airway resistance

27
PEEP
  • PEEPi in asthmatics
  • Adding PEEPe may help negative expiratory
    pressure gradient between alveoli and airway
  • Asthmatics are less responsive to this
    intervention
  • PEEP adds to auto-PEEP in asthmatics
  • If PEEPegtPEEPi
  • May worsen dynamic hyperinflation

Peigang Curr Opin Crit Care 20028(1)70-6.
28
Time to move on from Dynamic Hyperinflation
29
Asthmatic Patients
  • Who do we worry about?
  • Previously intubated
  • Noncompliant or poorly controlled
  • Psychosocial or emotional problems
  • Frequent flyers
  • Environmental triggers

30
What do we look for on exam?
  • Severe respiratory distress
  • Accessory muscle use
  • May be hypoxemic
  • Tachypneic
  • Tachycardic
  • Diaphoretic
  • Anxious
  • 1-2 word dyspnea

31
What do we do?
  • Rapid assessment
  • Manage the airway
  • Aggressive treatment
  • Respiratory therapist at bedside
  • Have all the needed equipment at the bedside
  • Intubation
  • Team approach
  • 2 IVs

32
Treatment
  • Albuterol neb
  • Atrovent neb
  • Solumedrol 125 mg IV
  • Terbutaline
  • 0.25 mg SQ
  • Epinephrine
  • 0.3 mg SQ or IM
  • Magnesium sulfate

33
Nebulized Treatments
  • Albuterol
  • Atrovent

34
Terbutaline
  • 0.25 mg SQ Q 20 minutes for 3 doses

35
EPI SQ vs IM
  • 0.2-0.5 cc Q 20-30 minutes for 3 doses
  • 11000 Epi

36
MgSO4
  • Possible inhibition of calcium influx into airway
    smooth muscle
  • Inhibits cholinergic neuromuscular transmission
  • Stabilization of mast cells and T lymphocytes
  • Stimulation of nitric oxide and prostacyclin

37
MgSO4
  • 5 intubated asthmatics
  • 10-20 grams /60 minutes
  • Decreased peak airway pressure
  • 3X increased Mg level with hypotension
  • Vasopressors in 2 patients

Sydow, Intensive Care Med 199319467-71
38
Other Scenarios
39
Pregnancy
  • Epinephrine
  • Concern re alpha effect and vasoconstriction in
    uteroplacental circulation
  • Avoid during pregnancy except in anaphylaxis
  • Terbutaline
  • Preterm labor
  • High dose steroids in animal studies
  • ??? cleft palate
  • Palatal closure usually by 12th week
  • Albuterol, Atrovent safe

40
Peds Acute severe asthma
  • Albuterol
  • 0.15mg/kg/hr
  • Albuterol continuous
  • 20 mg/hr if gt 20 kg
  • Atrovent
  • 0.5 mg/dose if gt 20 kg or gt 6y.o.
  • MgSO4
  • 25-75 mg/kg IV
  • Terbutaline
  • 10 mcg/kg IV over 10 minutes
  • Infusion of 0.1-10 mcg/kg/min

41
Heliox
  • Usually 70 Helium 30 oxygen
  • Inert gas
  • 3X reduction in density compared to air
  • Reduces resistance in airways with nonlaminar
    flow
  • Upper and Proximal
  • Reduces respiratory muscle work
  • May improve gas exchange
  • May increase the mass of albuterol delivered
  • Allows smaller particles to better penetrate the
    lung periphery
  • May use with
  • Face mask
  • BIPAP
  • Mechanical ventilation

42
Heliox
  • Work of breathing
  • Respiratory system compliance
  • Static property determined by elastic recoil of
    lung and chest wall
  • Airway resistance
  • Dynamic property
  • Density and viscosity of inspired gas
  • Airway caliber and configuration
  • Flow rate

McGarvey and Pollack Heliox in Airway Management,
Emerg Med Clin N Am 2008
43
Heliox
  • Decreased resistance to turbulent gas flow
  • in the absence of anatomic change
  • Higher flow rates for same driving pressure
  • May alleviate dynamic hyperinflation
  • Heliox seems to decrease the Reynolds number (Re)
    and facilitate laminar flow in patients with high
    airway resistance
  • Improved ventilation
  • Decreased work of breathing
  • Decreases the applied force required to achieve a
    given flow rate

44
Heliox
  • 12 adults in ED with severe asthma
  • 7 face mask, 5 ventilated
  • PCO2 gt45
  • 3-5 doses of nebulized albuterol
  • Significant decrease in PCO2
  • (57.9-47.5)
  • mean of 49 minutes after heliox
  • pH increased from 7.23-7.32
  • Improved ventilation in patients with acute
    severe asthma

Kass Chest 1995107757-60
45
Heliox ( severe asthma)
  • 3/7 with heliox via FM had symptoms gt 96 hours
  • 2- intubated
  • 4/7 with symptoms lt 24 hours not intubated
  • Conditions of all patients were sufficiently
    improved after 24 hours for heliox to be
    discontinued

Kass 1995
46
Heliox
  • Therapeutic bridge for 6-12 hour interval from
    patient arrival in ED
  • Failure of asthmatics to respond to heliox via
    mask may indicate increased risk for intubation

Kass 1995
47
Heliox
  • 23 adults with acute severe asthma
  • Randomized controlled trial
  • 20 minutes of heliox
  • Significant increase in PEFR ( 58 vs 10)
  • Significant decrease in dyspnea scores and RR
  • Maintenance of improvement over 8 hours

Kass Chest 1999116296-300
48
Heliox
  • Retrospective chart review of 22 ICU patients
    with status asthmaticus
  • Intubated
  • Significant drop in A-a gradient of heliox group
  • Allowed weaning of FiO2

Schaeffer Crit Care Med 1999272666-70.
49
Heliox (Peds)
  • 18 pediatric patients with status asthmaticus
  • Continuously inhaled nebulized B2 agonist
  • Solumedrol
  • Heliox (8020) vs room air at 10LPM by NRB
  • Heliox
  • Increased peak flow
  • Lessened the dyspnea score
  • 3 were not intubated (as planned)

Kudukis J Pediatr 1997130217-24
50
Heliox (Peds)
  • Retrospective review
  • 28 ventilated patients
  • Significant decrease in mean peak inspiratory
    pressures
  • 40.5-35.3
  • Mean PCO2 decreased significantly
  • 58.2-50.5

Abd-Allah Ped Crit Care Med 20034353-7.
51
Noninvasive Positive Pressure Ventilation and
Asthma
  • Controversial??????????????
  • Concern that it may
  • Worsen hyperinflation and air trapping,
  • Increase intrathoracic pressure
  • Decrease venous return and contribute to
    barotrauma
  • Not in my opinion!!!!!!!!!!!!!!!!!!!!!!!!!!!

52
CPAP
  • Seems to increase Functional residual capacity
    and lung compliance
  • May decrease fatigue of respiratory muscles
  • Decreases the adverse hemodynamic effects of
    large negative inspiratory swings in pleural
    pressure which compromise RV and LV performance

53
BIPAP
  • Provides CPAP
  • Delivers higher pressure in inspiration than
    expiration

54
Auto-PEEP
  • Universally found in asthma/COPD exacerbations
  • Adding PEEP (PEEPe) helps negative expiratory
    pressure gradient between alveolus and airway but
  • Asthmatics are less responsive to this
    intervention

Peigang, Curr Opin Crit Care 2002)
55
Noninvasive Positive Pressure Ventilation in
Status Asthmaticus
  • Medical ICU
  • NPPV in patients with hypercapneic respiratory
    failure
  • 17 episodes of asthma over 3 years
  • Face mask to ventilator
  • Initial CPAP 4/- 2 cm water
  • Pressure support ventilation (PSV) 14 /- 5 cm
    water
  • Meduri Chest 1996110767-74

56
Noninvasive Positive Pressure Ventilation
  • Goal of RR 25/min
  • Exhaled TV gt 7cc/kg
  • PSV adjusted following ABGs
  • Mean age 35
  • PCO2 at initiation 65

57
Noninvasive Positive Pressure Ventilation
  • Initial minute ventilation 16
  • Mean peak inspiratory pressures 18
  • Always lt 25 cm water
  • No complications with secretions
  • Mean duration 16 /- 21 hours

58
Noninvasive Positive Pressure Ventilation (NIPPV)
Time PCO2
Time 0 65 /- 2
lt 2 hours 52 /- 3
2-6 hours 45 /- 3
12-24 hours 45 /- 4
59
NIPPV
  • Respiratory muscles rapidly unloaded
  • Dyspnea improved
  • RR improved
  • Gas exchange improved with low inspiratory
    pressure
  • 12 of patients with NIPPV were intubated

60
Mask-CPAP
  • Causes bronchodilation and decreases airway
    resistance
  • Reexpands atelectasis and promotes removal of
    secretions
  • Rests the diaphragm and inspiratory muscles and
    may offset PEEPi
  • Decreases the adverse effects of large negative
    peak and mean inspiratory pleural pressures

61
Non-invasive mechanical ventilation in status
asthmaticus
  • 7 year retrospective, observational study
  • 1992-1998
  • FM NIMV
  • 22 patients
  • 3 were later intubated
  • Improved alveolar ventilation and reduced the
    need for intubation in a selected group of
    patients with status asthmaticus
  • Fernandez Intensive Care Med 200127486-92

62
NIMV
  • Face mask NIMV
  • CPAP
  • Fixed values of 5 and 7.5 cm water
  • Keep sat above 90
  • Pressure support ventilation
  • Commercial ventilator
  • Titrated to achieve minimum of 400 cc of expired
    tidal volume
  • Increased in increments of 3 cm water in
    accordance with patients requirements
  • PEEP used until a substantial improvement in
    effort required to trigger the ventilator was
    noted

63
NIMV
Time PCO2
ED 53 / 13
ICU 63 /- 24
2-6 hour 51 /- 24
6-12 hour 48 /- 14
64
NIMV
  • May start with low level inspiratory pressure
    support 5-7 cm water
  • PEEP 3-5 cm water
  • Pressure support increased by 2cm water every 15
    min
  • Goal
  • RR lt 25
  • Peak inspiratory pressures lt 25

65
NIMV in Pediatric Status Asthmaticus
  • 3 children 9,11,15
  • Hypercarbic respiratory failure
  • Mean CO2 54.6
  • BIPAP
  • Inspiratory positive pressure 10-14 cm water
  • Expiratory pressure 4-5 cm water

Akingbola Crit Care Med 20023(2)181-184
66
NIMV Pediatric Status Asthmaticus
  • Duration of therapy 12-17 hours
  • RR decreased
  • PCO2 decreased
  • Improved ventilation and gas exchange

67
My Conclusion
  • BIPAP is worth a try if it can be tolerated by
    the patient

68
What about Heliox and Noninvasive Ventilation
69
Heliox and Noninvasive Ventilation (NIV)
  • Acute exacerbation of COPD
  • 10 patients
  • NIV Heliox at 2 levels of PSV
  • (9/- 2), (18 /- 3) vs
  • NIV (air O2)
  • Significant reductions in
  • Pressure-time index at both PSV
  • Work of breathing
  • PCO2
  • NIV with heliox
  • Reduce patient effort and improve gas exchange

Jaber Am J Respir Crit Care Med 2001611191-2000
70
Noninvasive Pressure Support and Heliox
  • Decompensated COPD
  • MICU
  • 19 patients with severe COPD
  • Noninvasive pressure support
  • Randomized crossover design
  • 45 minutes with airoxygen or heliox
  • No ventilation for 45 minutes
  • 45 minutes with airoxygen or heliox
  • Jolliet Critical Care Med 199927(11)2422-2429

71
Noninvasive Pressure Support and Heliox
  • Reduced dyspnea and PCO2 more than airoxygen
  • Did not modify blood pressure
  • May reduce the need for intubation

Jolliet 1999
72
Ketamine
  • What is its role?
  • Could it prevent need for intubation?
  • Bronchodilator
  • May increase airway secretions
  • Emergence reactions

73
Case 2 Many Years ago
  • Status asthmaticus patient
  • Multiple aggressive treatments
  • Not using heliox, BIPAP or IV Epi at that time
  • Preparing to intubate
  • Patient was given 2mg/kg of Ketamine
  • This was followed by increased lung expansion
  • Minimal bronchospasm was noted
  • Reassessed patient- No need for intubation
  • AMA from the ICU

74
Epinephrine IV
75
Epi IV
  • Where is the literature?
  • I treat refractory status asthmaticus
  • with IV Epi
  • Similar to anaphylaxis
  • How do we dose Epi?
  • How many different ways are listed in our
    literature?
  • I add 1 mg of Epi to a 250 cc bag
  • 4mcg/cc
  • Start a drip and titrate

76
When to Intubate
  • When do you intubate an asthmatic patient?
  • Persistent hypercarbia
  • Hemodynamic instability
  • Inability to tolerate the face mask, BIPAP..
  • Exhaustion
  • Altered mental status.

77
Mechanical Ventilation
  • Minimize high airway pressures and barotrauma
  • Minute ventilation lt 10 L/min
  • Permissive hypercapnea
  • Low tidal volumes (6-10 cc/kg)
  • Low ventilation rates ( lt 10 /min)
  • Plateau pressures lt 30 cm water
  • Inspiratory flow rate 60-80 l/min
  • No PEEP

Oddo, Intensive Care Med 200632501-10
78
Mechanical Ventilation
  • Monitor effect of PEEP on auto-PEEP
  • PEEP has been reported to add to auto-PEEP in
    patients with asthma
  • If PEEPe is set higher than PEEPi, it may worsen
    dynamic hyperinflation
  • Volume-targeted Plateau Pressure
  • Pressure-targeted Tidal Volume

Peigang Curr Opinion in Critical Care 2002870-76
79
Mechanical Ventilation
  • Controlled hypoventilation
  • Monitor lung hyperinflation
  • Maintain patient/ventilator synchrony
  • Watch neuromuscular blockers

Oddo 2006
80
Mechanical Ventilation
  • 30 of patients with near-fatal asthma who were
    administered neuromuscular blockers
  • Acute myopathy
  • Limit their use to lt 24 hours

Behbehani Chest 19991151627-31
81
Ventilatory modes
  • Pressure control
  • Inspiration ceases when a preset maximum pressure
    is reached
  • Delivered volume varies depending upon lung
    mechanics
  • Minute ventilation is not assured

82
Pressure support
  • Flow-cycled-
  • When it is triggered by a demand valve, the
    preset pressure is sustained until the
    inspiratory flow tapers, usually to 25 of its
    maximal value
  • Clinician determines the final airway pressure,
    TV and RR
  • Decreases patient-ventilator dyssynchrony
  • Functionally-
  • Equivalent to BIPAP

83
Volume control
  • Inspiration is terminated after the delivery of a
    preset TV
  • Peak pressures may be elevated

84
Pressure regulated volume control
  • Assures that the patient receives the desired
    Tidal Volume at the lowest peak pressure

85
PEEP
  • Extrinsic PEEP in the ventilated asthmatic
    patient is controversial
  • PEEP may
  • Open collapsed airways
  • Improve ventilation
  • Potentially reduce air trapping

86
General Anesthesia
  • Considered with
  • Elevated airway pressures
  • Persistent hypoxemia
  • Continued bronchospasm
  • Isoflurane

87
Case 3
  • 33 y.o. Indonesian male
  • Crescendo dyspnea over 24 hours
  • 2 prior intubations
  • ED treatment
  • Nebulized treatments, steroids, MgSO4
  • Admitted for observation
  • Day 2 intubated

Mikkelsen Resp Care 200752(11)1525-1520
88
Case 3
  • Profound bronchospasm
  • Hypercapnea, acidosis
  • Deep sedation
  • CO2 (84) on the ventilator
  • 2 hours after intubation
  • Peak inspiratory pressure gt 60
  • Plateau and intrinsic PEEP gt 30 cm water

89
Case 3
  • Attempts to minimize dynamic hyperinflation
  • Prolonging the expiratory time
  • Decreasing the respiratory rate
  • Higher inspiratory flow ( 80 LPM) limited by
    higher airway pressure
  • PCO2 prior to vecuronium was 94
  • Vecuronium
  • Peak inspiratory pressures decreased to 50 cm
    water
  • Plateau pressure decreased to 15 cm water
  • Intrinsic PEEP decreased to 5 cm water

90
Case 3
  • Over the next 3 hours
  • Intrinsic PEEP to 30 cm water
  • Peak airway pressure gt 75 despite
  • Respiratory minute ventilation at 3LPM
  • TV ( 450-200)
  • RR 10/min
  • Eventually he was receiving lt 50 cc with any
    ventilation mode

91
Case 3
  • Venovenous Extracorporeal Life Support (ECLS) to
    counteract the severe dynamic hyperinflation and
    impending cardiac arrest

92
Case 3
  • 20 minutes after ECLS
  • Hypotensive
  • Phenylephrine
  • Vasopressor weaned over the next several hours
  • Weaned off ECLS 55 hours after initiation
  • Hospital day 10 extubated
  • Discharged to home after 21 hospital days

93
Extracorporeal life support (ECLS)
  • Extracorporeal membrane oxygenation
  • Modified heart-lung machine for days or weeks to
    support life and permit treatment and recovery
    during severe cardiac or pulmonary failure

94
Extracorporeal Life support
  • Venovenous access and perfusion method of choice
    for respiratory support since 1988
  • Percutaneous cannulation of
  • Right atrium via the jugular vein ( 16F)
  • IVC via femoral vein ( 22F Heartport long venous
    catheter)
  • Connected to the ECLS circuit
  • Femoral-atrial flow at 3.5 L/Min

95
Extracorporeal Life Support
  • Since 1988- venovenous access and perfusion
  • Battery operated
  • Passive support of gas exchange and perfusion
  • Low pressure, low oxygen ventilator settings

96
Consider ECLS
  • Despite institution of hypoventilation and while
    tolerating increased peak inspiratory pressure
  • pH lt 7.2
  • PCO2 gt 100
  • Life threatening conditions due to hypoxemia,
    hypotension or barotrauma

97
Summary
  • Look for the sick asthmatics
  • Be aggressive in their treatment
  • Do not forget about
  • Terbutaline ( SQ)
  • Epi ( SQ or IM)
  • If they are young and fighting, consider
  • BIPAP
  • Heliox
  • IV Epinephrine
  • Intubate if the patient is
  • Fatigued
  • Unable to cooperate with interventions

98
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