Invasive mechanical ventilation in adults with acute exacerbations of asthma
- Carey C Thomson, MD, MPH
Carey C Thomson, MD, MPH
- Assistant Professor,
- Harvard Medical School
- Kohei Hasegawa, MD, MPH
Kohei Hasegawa, MD, MPH
- Assistant Professor
- Harvard Medical School
Intensive therapy with inhaled bronchodilators and systemic glucocorticoids is usually sufficient to reduce airflow obstruction and ameliorate symptoms in patients with acute asthma exacerbations. However, 3 to 5 percent of all patients hospitalized for acute asthma exacerbation develop respiratory failure and require invasive mechanical ventilation [1-4]. Although potentially life-saving, mechanical ventilation and its associated interventions (eg, sedatives, paralytics) can also cause morbidity and mortality [5-9].
In this topic review, the indications, management, and adverse effects of invasive mechanical ventilation in patients with severe acute asthma exacerbation will be reviewed. The pharmacologic treatment of acute exacerbations of asthma and the role of noninvasive positive pressure ventilation are discussed separately. (See "Management of acute exacerbations of asthma in adults" and "Noninvasive ventilation in acute respiratory failure in adults".)
The primary indication for mechanical ventilation in an acute asthma exacerbation is acute respiratory failure (ie, insufficient oxygenation or alveolar ventilation). The decision to initiate mechanical ventilation should be based on serial clinical evaluations that consider the severity of airflow limitation (eg, peak expiratory flow), degree of respiratory difficulty (eg, respiratory rate >40/minute, inability to talk), clinical findings (eg, accessory muscle use, intercostal retractions, fatigue, somnolence), hypoxemia, hypercapnia (elevated arterial tension of carbon dioxide [PaCO2]), and response to therapy [10,11]. Bronchoconstriction can worsen abruptly after placement of an endotracheal tube, so the need for ventilatory support must be weighed against the potential for initial worsening of ventilation. Nonetheless, intubation and mechanical ventilation should not be delayed until the need becomes emergent.
Generally, acute asthma exacerbations are associated with mild hyperventilation and a low PaCO2. However, with worsening airflow limitation, the high work of breathing leads to fatigue, a resultant decrease in the minute ventilation, and an increase in PaCO2. Thus, during an acute asthma exacerbation, a PaCO2 of 42 mmHg or greater, while technically "normal," may suggest incipient respiratory failure. On the other hand, hypercapnia alone is not an indication for mechanical ventilation in the absence of decreased mental status or exhaustion.
The optimal role of noninvasive positive pressure ventilation (NPPV), including biphasic positive airway pressure and continuous positive airway pressure ventilation, in acute asthma exacerbations is unclear [3,12-17]. However, a brief trial of NPPV may be reasonable in selected patients prior to intubation and mechanical ventilation [3,17-19]. Failure of NPPV to improve oxygenation would be an indication for invasive mechanical ventilation. (See "Noninvasive ventilation in acute respiratory failure in adults", section on 'Asthma'.)
Subscribers log in hereLiterature review current through: Nov 2017. | This topic last updated: Oct 09, 2017.References
- Krishnan V, Diette GB, Rand CS, et al. Mortality in patients hospitalized for asthma exacerbations in the United States. Am J Respir Crit Care Med 2006; 174:633.
- Nanchal R, Kumar G, Majumdar T, et al. Utilization of mechanical ventilation for asthma exacerbations: analysis of a national database. Respir Care 2014; 59:644.
- Stefan MS, Nathanson BH, Lagu T, et al. Outcomes of Noninvasive and Invasive Ventilation in Patients Hospitalized with Asthma Exacerbation. Ann Am Thorac Soc 2016; 13:1096.
- Hasegawa K, Bittner JC, Nonas SA, et al. Children and Adults With Frequent Hospitalizations for Asthma Exacerbation, 2012-2013: A Multicenter Observational Study. J Allergy Clin Immunol Pract 2015; 3:751.
- Scoggin CH, Sahn SA, Petty TL. Status asthmaticus. A nine-year experience. JAMA 1977; 238:1158.
- Mansel JK, Stogner SW, Petrini MF, Norman JR. Mechanical ventilation in patients with acute severe asthma. Am J Med 1990; 89:42.
- Anzueto A, Frutos-Vivar F, Esteban A, et al. Incidence, risk factors and outcome of barotrauma in mechanically ventilated patients. Intensive Care Med 2004; 30:612.
- Hodder R, Lougheed MD, FitzGerald JM, et al. Management of acute asthma in adults in the emergency department: assisted ventilation. CMAJ 2010; 182:265.
- Schatz M, Kazzi AA, Brenner B, et al. Joint task force report: supplemental recommendations for the management and follow-up of asthma exacerbations. Introduction. J Allergy Clin Immunol 2009; 124:S1.
- Brenner B, Corbridge T, Kazzi A. Intubation and mechanical ventilation of the asthmatic patient in respiratory failure. J Allergy Clin Immunol 2009; 124:S19.
- Wu RS, Wu KC, Wong TK, et al. Effects of fenoterol and ipratropium on respiratory resistance of asthmatics after tracheal intubation. Br J Anaesth 2000; 84:358.
- Soroksky A, Stav D, Shpirer I. A pilot prospective, randomized, placebo-controlled trial of bilevel positive airway pressure in acute asthmatic attack. Chest 2003; 123:1018.
- Gupta D, Nath A, Agarwal R, Behera D. A prospective randomized controlled trial on the efficacy of noninvasive ventilation in severe acute asthma. Respir Care 2010; 55:536.
- Brandao DC, Lima VM, Filho VG, et al. Reversal of bronchial obstruction with bi-level positive airway pressure and nebulization in patients with acute asthma. J Asthma 2009; 46:356.
- Galindo-Filho VC, Brandão DC, Ferreira Rde C, et al. Noninvasive ventilation coupled with nebulization during asthma crises: a randomized controlled trial. Respir Care 2013; 58:241.
- Lim WJ, Mohammed Akram R, Carson KV, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev 2012; 12:CD004360.
- Bergin SP, Rackley CR. Managing Respiratory Failure in Obstructive Lung Disease. Clin Chest Med 2016; 37:659.
- Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S501.
- Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA). www.ginasthma.org (Accessed on January 27, 2017).
- Corbridge TC, Hall JB. The assessment and management of adults with status asthmaticus. Am J Respir Crit Care Med 1995; 151:1296.
- Brenner B, Corbridge T, Kazzi A. Intubation and mechanical ventilation of the asthmatic patient in respiratory failure. Proc Am Thorac Soc 2009; 6:371.
- Mannam P, Siegel MD. Analytic review: management of life-threatening asthma in adults. J Intensive Care Med 2010; 25:3.
- Tuxen DV. Permissive hypercapnic ventilation. Am J Respir Crit Care Med 1994; 150:870.
- Gladwin MT, Pierson DJ. Mechanical ventilation of the patient with severe chronic obstructive pulmonary disease. Intensive Care Med 1998; 24:898.
- Douglass JA, Tuxen DV, Horne M, et al. Myopathy in severe asthma. Am Rev Respir Dis 1992; 146:517.
- Kupfer Y, Namba T, Kaldawi E, Tessler S. Prolonged weakness after long-term infusion of vecuronium bromide. Ann Intern Med 1992; 117:484.
- Smith TC, Marini JJ. Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction. J Appl Physiol (1985) 1988; 65:1488.
- Leatherman J. Mechanical ventilation for severe asthma. Chest 2015; 147:1671.
- Rosengarten PL, Tuxen DV, Dziukas L, et al. Circulatory arrest induced by intermittent positive pressure ventilation in a patient with severe asthma. Anaesth Intensive Care 1991; 19:118.
- Kollef MH. Lung hyperinflation caused by inappropriate ventilation resulting in electromechanical dissociation: a case report. Heart Lung 1992; 21:74.
- Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 8: advanced challenges in resuscitation: section 3: special challenges in ECC. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation 2000; 102:I229.
- Perkins GD, Augré C, Rogers H, et al. CPREzy: an evaluation during simulated cardiac arrest on a hospital bed. Resuscitation 2005; 64:103.
- Leatherman JW, McArthur C, Shapiro RS. Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Crit Care Med 2004; 32:1542.
- Leatherman JW, Ravenscraft SA. Low measured auto-positive end-expiratory pressure during mechanical ventilation of patients with severe asthma: hidden auto-positive end-expiratory pressure. Crit Care Med 1996; 24:541.
- Saulnier FF, Durocher AV, Deturck RA, et al. Respiratory and hemodynamic effects of halothane in status asthmaticus. Intensive Care Med 1990; 16:104.
- Johnston RG, Noseworthy TW, Friesen EG, et al. Isoflurane therapy for status asthmaticus in children and adults. Chest 1990; 97:698.
- Hemming A, MacKenzie I, Finfer S. Response to ketamine in status asthmaticus resistant to maximal medical treatment. Thorax 1994; 49:90.
- Maltais F, Sovilj M, Goldberg P, Gottfried SB. Respiratory mechanics in status asthmaticus. Effects of inhalational anesthesia. Chest 1994; 106:1401.
- Heshmati F, Zeinali MB, Noroozinia H, et al. Use of ketamine in severe status asthmaticus in intensive care unit. Iran J Allergy Asthma Immunol 2003; 2:175.
- Tobias JD. Inhalational anesthesia: basic pharmacology, end organ effects, and applications in the treatment of status asthmaticus. J Intensive Care Med 2009; 24:361.
- Gluck EH, Onorato DJ, Castriotta R. Helium-oxygen mixtures in intubated patients with status asthmaticus and respiratory acidosis. Chest 1990; 98:693.
- Manthous CA, Hall JB, Caputo MA, et al. Heliox improves pulsus paradoxus and peak expiratory flow in nonintubated patients with severe asthma. Am J Respir Crit Care Med 1995; 151:310.
- Kress JP, Noth I, Gehlbach BK, et al. The utility of albuterol nebulized with heliox during acute asthma exacerbations. Am J Respir Crit Care Med 2002; 165:1317.
- Schaeffer EM, Pohlman A, Morgan S, Hall JB. Oxygenation in status asthmaticus improves during ventilation with helium-oxygen. Crit Care Med 1999; 27:2666.
- Rodrigo G, Pollack C, Rodrigo C, Rowe BH. Heliox for nonintubated acute asthma patients. Cochrane Database Syst Rev 2006; :CD002884.
- Tassaux D, Jolliet P, Thouret JM, et al. Calibration of seven ICU ventilators for mechanical ventilation with helium-oxygen mixtures. Am J Respir Crit Care Med 1999; 160:22.
- Shapiro MB, Kleaveland AC, Bartlett RH. Extracorporeal life support for status asthmaticus. Chest 1993; 103:1651.
- Kukita I, Okamoto K, Sato T, et al. Emergency extracorporeal life support for patients with near-fatal status asthmaticus. Am J Emerg Med 1997; 15:566.
- Mikkelsen ME, Woo YJ, Sager JS, et al. Outcomes using extracorporeal life support for adult respiratory failure due to status asthmaticus. ASAIO J 2009; 55:47.
- Marquette CH, Saulnier F, Leroy O, et al. Long-term prognosis of near-fatal asthma. A 6-year follow-up study of 145 asthmatic patients who underwent mechanical ventilation for a near-fatal attack of asthma. Am Rev Respir Dis 1992; 146:76.
- Yellowlees PM, Ruffin RE. Psychological defenses and coping styles in patients following a life-threatening attack of asthma. Chest 1989; 95:1298.
- Global Initiative for Asthma. Global strategy for asthma management and prevention, revised 2014. http://www.ginasthma.org/documents/4 (Accessed on January 06, 2015).
- GENERAL APPROACH
- Induction agents
- Ventilator mode
- Initial ventilator settings
- Administering inhaled bronchodilator
- TROUBLESHOOTING HIGH PEAK PRESSURES
- Differentiating airway and lung parenchymal causes of high pressures
- Dynamic hyperinflation
- - Assessment
- - Adverse effects of dynamic hyperinflation
- - Adjustments to decrease dynamic hyperinflation
- - Adding extrinsic PEEP to offset intrinsic PEEP
- Permissive hypercapnia
- TROUBLESHOOTING HYPOXEMIA
- ADDITIONAL AND UNCONVENTIONAL THERAPIES
- General anesthesia
- Extracorporeal life support
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS