Status Asthmaticus

Question 1

Status Asthmaticus

ASAP:

Answer 1

ABCs, IV, Monitor, O2 (maintain SaO2 >90, >95 if pregnant/underlying CAD hx) EtCO2 / Capnography

Question 2

Status Asthmaticus

Hx/Exam:

Answer 2

Prior admissions/ intubations, recent steroids, meds, fever, anaphylaxis, FB, vaccines, Hx COPD/CHF; accessory muscles,
RR, wheezing, air movement, anxiety, triggers (ASA,NSAIDS, B blockers, ACE I, exercise, pollon)

Question 3

Status Asthmaticus

Labs/Rads:

Answer 3

May not need any, ABG (Pao2 ≤ 60 or Paco2 ≥ 42 is severe), CBC, lytes, EKG and cardiac labs if old, CXR, PEFR (if predicted best <40% then severe)

Question 4

Status Asthmaticus

Treatment:
NIPPV:

Answer 4

Consider early 8-10/0-5
Severe are fatigued→ not moving air–>need inhalation support (can help exhale)

Question 5

Status Asthmaticus

Treatment: High flow nasal cannula

Answer 5

20-30 LPM

Question 6

Status Asthmaticus

Treatment: Albuterol

Answer 6

5 mg neb x 3 q 20 min, or continuous if severe (1/2 dose in peds)
Minimal benefit in severe asthma

Question 7

Status Asthmaticus

Treatment: Atrovent

Answer 7

0.5 mg neb x 3 q 20 min, continuous for 1 hr if severe (1/2 dose in peds)

Question 8

Status Asthmaticus

Treatment: Solu Medrol

Answer 8

125 -250 mg IV (2 mg/kg peds)
Decrease inflammation in 4-6 hours, upregulate B receptors in lungs in 1 hr

Question 9

Status Asthmaticus

Treatment: Magnesium

Answer 9

75 mg/kg (max 2g) over 20 min
Bronchial smooth muscle relax- minimal evidence

Question 10

Status Asthmaticus

Treatment: Epinephrine

Answer 10

0.3-0.5 mg (1:1000) IM q 20 min x 3, 1-5 mcg/min (1:10000) IV- caution in pregnancy
Non selective B and A→ bronchodilation, vasoconstriction increase cardiac contractility, increase HR
Good for severe asthma

Question 11

Status Asthmaticus

Treatment: Terbutaline

Answer 11

0.5 mg SC q 20 min x 3
Selective parenteral B2 → bronchodilation

Question 12

Status Asthmaticus

Treatment: Heliox 80/20

Answer 12

Improved laminar flow, limited amount of FiO2

Question 13

Status Asthmaticus

Treatment: Ketamine

Answer 13

• 0.1 mg/kg → 0.5 mg/kg/hr for 3 hours
• Subdissociative, can help with NIV

Question 14

Status Asthmaticus

Treatment: IVF

Answer 14

30cc/kg
nsensible losses, lung hyperinflation → decrease pulmonary venous return –>hypotension

I

Question 15

Status Asthmaticus

Treatment: If resp failure…

Answer 15

Intubate with large-bore ETT; use Ketamine 1-2mg/kg IV (may obviate ETT), and Sux 1.5 mg/kg IV or Rocuronium 1
mg/kg IV

Question 16

Status Asthmaticus

Treatment: If intubated…

Answer 16

Allow permissive hypercapnia, prevent stacking, avoid dynamic hyperinflation and give prolonged expiratory phase
RR 6-10, Vt 6-8 ml/kg, FiO2 maintain O2 > 93%, inspiratory flow rate 100-120, I:E 1:4-8
Check plateau pressures- goal < 30
DOPES: displacement, obstruction, PTX, equipment failure, stacked breaths

Question 17

Status Asthmaticus

Increase risk of death

Answer 17

Hx of sudden severe exacerbations, prior intubation or ICU admission, 2+ admission in last year, 3+ ED visits in the last year,
admission or ED visit in the last month, use of more than 2 short acting B agonist, current use of steroid or recent withdrawal,
comorbidities, psychosocial problems, drug use

Question 18

Status Asthmaticus

Sub-types

Answer 18

Pediatric
Aspirin -exacerbated respiratory disease
change in balance of mediators, nasal polyps, eosinophilic sinusitis, 3rd decade of life, severe
Menstruation-associated
Psychological factors
Exercise- associated with atopy