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com/content/9/6/581
Review
Clinical review: Mechanical ventilation in severe asthma
David R Stather1 and Thomas E Stewart2
1Fellow, InterDepartmental Division of Critical Care Medicine and Division of Respirology, Department of Medicine, Mount Sinai Hospital and University
Published online: 8 September 2005 Critical Care 2005, 9:581-587 (DOI 10.1186/cc3733)
This article is online at http://ccforum.com/content/9/6/581
© 2005 BioMed Central Ltd
NPPV = noninvasive positive pressure ventilation; PEEP = positive end-expiratory pressure; Pplat = plateau airway pressure; VEI = volume of gas at
end-inspiration above functional residual capacity. 581
Critical Care December 2005 Vol 9 No 6 Stather and Stewart
Figure 2
Measuring lung hyperinflation using VEI. VEI, volume of gas at end-inspiration above functional residual capacity. Reproduced with permission from
Tuxen [43].
minimizing the use of extrinsic PEEP or not using it at all reports of successful use of these agents in refractory status
[35,36] in the ventilation of patients with severe asthma. If asthmaticus [49,50]. The special equipment and personnel
extrinsic PEEP is to be used, then careful bedside obser- needed for inhalation anaesthesia and the significant
vation with a clear understanding of how the benefits haemodynamic complications associated with these agents
(reductions in auto-PEEP) and adverse effects (worsening make their use problematic. Ketamine is an intravenous agent
gas-trapping) would manifest is mandatory. that has analgesic and bronchodilating properties [51]. There
are limited clinical data available regarding the use of
Considerations for initial ventilator settings ketamine in status asthmaticus [52,53], and its side effects of
in patients with severe asthma tachycardia, hypertension, delirium and lowering the seizure
There have been a number of review articles recommending threshold should always be taken into account.
initial ventilator settings and algorithmic approaches to
mechanical ventilation in severe asthma [6,7]. The fine details In patients with status asthmaticus and severe mucous
of the ventilator settings are not as crucial as close attention impaction, it has been suggested that bronchoscopic
to the basic principles of ventilating patients with severe examination of the airways and removal of secretions may be
asthma: employ low tidal volumes and respiratory rate; beneficial [54]. As the presence of the bronchoscope may
prolong expiratory time as much as possible; shorten worsen lung hyperinflation and increase the risk for
inspiratory time as much as possible; and monitor for the pneumothorax [55], we do not recommend this technique.
development of dynamic hyperinflation.
Heliox is a blend of helium and oxygen (usually at a 70 : 30
As a starting point for ventilating patients with severe asthma, ratio), which is less dense than air, theoretically permitting
we recommend that the ventilator initially be used in pressure higher flow rates through a given airway segment for the
control mode, setting the pressure to achieve a tidal volume same driving pressure, thereby alleviating dynamic
of 6–8 ml/kg, respiratory rate of 11–14 breaths/min and hyperinflation. Several small studies have shown heliox to
PEEP at 0–5 cmH2O. We use these settings with a goal of reduce peak inspiratory pressure and arterial carbon dioxide
obtaining a pH, in general, above 7.2 and a Pplat under tension, and to improve oxygenation in mechanically
30 cmH2O. If a Pplat under 30 cmH2O cannot be maintained, ventilated patients [56,57]. That heliox is expensive, has a
then the patient must be evaluated for causes of decreased limited concentration of oxygen and has conflicting results in
respiratory system compliance (i.e. pneumothorax, misplaced the literature [58-61] make it a somewhat controversial
endotracheal tube, pulmonary oedema, etc.) beyond the therapy, and at this time we cannot recommend it for routine
development of dynamic hyperinflation. If no such causes are use in severe asthma.
evident then efforts to limit gas-trapping further must be
considered. If permissive hypercapnia results in a pH below Extracorporeal membrane oxygenation is another expensive
7.2, then the same type of evaluation needs to occur, modality that has been successfully used in patients with
including consideration of increased sedation/paralysis and severe refractory asthma [62,63]. The use of these second-
methods of decreasing carbon dioxide production (i.e. line therapies should be on a case-by-case basis, carefully
reducing fever, preventing over-feeding, decreasing patient weighing the risks and benefits.
effort, etc.). In addition to these examples, administration of
sodium bicarbonate to maintain a pH of 7.2 during controlled Conclusion
hypoventilation has been investigated in patients with status Severe asthma exacerbation causing respiratory failure has
asthmaticus [44]; however, no studies have demonstrated not yet been eliminated, and remains a potentially reversible,
any benefit associated with bicarbonate infusion. Decisions life-threatening condition that imposes significant morbidity
regarding ongoing ventilator management must be based on and mortality. When mechanical ventilation is required in
the principles outlined in this review. severe asthma, it is important that clinicians managing these
patients understand why gas-trapping occurs, how to
Adjuncts to mechanical ventilation measure it and how to limit its severity. We hope that by
A large variety of unproven therapies that clinicians may need understanding such concepts clinicians will be able to
to consider in an emergent situation have been proposed, reduce further the number of poor outcomes that are
including intravenous magnesium sulphate, general anaes- occasionally associated with severe asthma.
thesia, bronchoscopic lavage, heliox and extracorporeal
membrane oxygenation. Competing interests
The author(s) declare that they have no competing interests.
Intravenous magnesium sulphate has bronchodilating
properties and has been shown in limited studies to improve
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