Contributor: Aaron Lessen, MD

Educational Pearls:

• The management of severe asthma or COPD exacerbation is complex, especially when the patient requires intubation/ventilation
• Asthma is an obstructive airway disease that can cause air trapping and hyperinflation of the lungs
• To avoid worsening hyperinflation patients typically require slower respiratory rates, lower tidal volumes, and increased expiratory time when on a ventilator
• • Patients on a ventilator require very close monitoring to prevent worsening hyperinflation and associated complications including barotrauma and hypotension/cardiac arrest secondary to decreased venous return
• If patient condition starts to worsen, decrease respiratory rate and tidal volume
• • In these cases, a decreased oxygen saturation is acceptable until their condition improves
• If patient status continues to worsen, consider disconnecting the ventilator and pushing on the chest for approximately 30 seconds to help force out trapped air
• If patient continues to decompensate, consider the possibility of a pneumothorax and determine if a chest tube is necessary
• Remember to continue asthma/COPD management including albuterol/duonebs, steroids, magnesium, and alternatives including as heliox

References

Demoule A, Brochard L, Dres M, et al. How to ventilate obstructive and asthmatic patients. Intensive Care Med. 2020;46(12):2436-2449

Garner O, Ramey JS, Hanania NA. Management of Life-Threatening Asthma: Severe Asthma Series. Chest. 2022

Laher AE, Buchanan SK. Mechanically Ventilating the Severe Asthmatic. J Intensive Care Med. 2018;33(9):491-501

Summarized by Mark O'Brien, MS4 | Edited by John Spartz MD & Erik Verzemnieks, MD

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