2. What We Will Talk About
Treatment of Severe Asthma in ED
What works and What Does Not
Treatment of the Crashing Asthmatic
What We Won‟t Talk About
• Treatment of the Mild-Moderate Asthmatic
6. Risk Factors for Death in Asthma
Previous severe exacerbation (ICU/intubation)
2 or more hospitalizations for asthma in 1 year
3 or more ED for asthma in 1 year
Hospitalization/ED visit for asthma in last month
Using >2 MDI short acting β2 agonists in last month
Current or recent use steroids
8. β2-agonists
Camargo CA et al. Continuous versus intermittent beta-agonists
for acute asthma. Cochrane Database Syst Rev. 2003;(4):C
N = 461 Adults and pediatric
Participants got either:
10-30mg albuterol over 2-4 hours OR q20 minute nebulizers,
q30 minute nebulizers, or q1 hour nebulizers.
90% saw no benefit
10% decreased hospital admission rate
CONTINUOUS IS BETTER
9. Ipratropium
The nnt looked at 6 meta-analyses from 1999-2006
Ipratroprium added to beta 2 agonist therapy
N = 1500
Decrease in hospital admission by 9%
NNT = 11.5 (11.5 treated to prevent 1 admission)
3 nebules is the max for 6 hours
IPRATROPIUM GOOD
10. Steroids
Rowe BH et al. Early emergency department treatment of acute
asthma with systemic corticosteroids. Cochrane Database Syst
Rev. 2001;(1):CD002178
12 studies- Steroids given within 1 hour. Both pediatric (PO)
and adult (IV/IM). Followed up between 3 and 21 days.
N = 863
NNT = 5
12.5% were helped by preventing hospital admission
10.0% were helped by preventing asthma relapse
9.1% were helped by preventing a later hospital admission
GIVE STEROIDS
11. Mainstays in Treatment
β2-agonists
Hit „em hard, hit „em long
Anticholinergics
Especially effective in children
3 nebules max for 6 hours
Steroids
Give early but will take time to work
12. Trivia
This resident competed in an Ironman and has the tattoo
to prove it. Additionally, she has this license plate:
15. Magnesium
BH et al. Magnesium sulfate for treating exacerbations of acute
asthma in the emergency department. Cochrane Database Syst Rev.
2000;(2):CD001490.
N = 665 Both pediatric and adult
Most studies gave as bolus (1.2-2gm/20 min, or peds 25-
100mg/kg). 6/7 gave within 1st hour
67% no benefit
33.3% severe asthmatics prevented hospital admission
For severe NNT =2
100% non-severe asthmatics were neither harmed/helped
GIVE MAGNESIUM EARLY
16. IV Epinephrine
Potent, Reduces Airway Resistance
α effect leads to vasoconstriction
1:10000 (crash cart epi)
0.25cc is a 25mcg push if crashing
2.5cc in 250mL NS (1mcg/mL sol‟n) run over 25 min
(10mcg/min)
17. Non-invasive Positive Pressure
Ventilation
Non-invasive positive pressure ventilation for treatment of respiratory
failure due to severe acute exacerbations of asthmaLim WJ, Mohammed
Akram R, Carson KV, Mysore S, Labiszewski NA, Wedzicha JA, Rowe BH,
Smith BJ. December 12, 2012
6 trials, N =206
Compared to usual medical care alone, NPPV reduced hospitalizations,
increased the number of patients discharged from the emergency
department, and improved respiratory rate and lung function
measurements. The application of NPPV in patients with asthma, despite
some promising preliminary results, still remains controversial. Further
studies are needed to determine the role of NPPV in the management of
severe acute asthma and especially in status asthmaticus.
Increases FRC, Decreases WOB
USE NPPV
18. Trivia
This resident is a former cheerleader, went to the best
medical school in the country, hates public speaking, and
is a bad ass rock climber.
21. Intubation
18% mortality if intubated. Probably lower now that we
have better vent settings
Death-asphyxia, tension ptx, reduced venous return
Diaphoretic/Decreased responsiveness
22. Intubate
Lidocaine (1.5mg/kg)
IV or inhaled
Reduces airway responsiveness
Ketamine (1-1.5mg/kg)
Weak bronchodilator
Can consider (0.5mg/kg) in agitated patient
Succ (1.5mg/kg) or Roc (1mg/kg)
Recommend giving ketamine/lido while sitting up and then
laying down and pushing paralytics. Also recommend most
experienced person place ET tube
Have the cric ready
23. Ventilator Settings
Barotrauma, Breathstaking, DEATH
Initial RR 6-8 breaths/min (DO NOT HYPERVENTILATE)
Small TV 5-7cc/kg
Small PEEP (0 or 2)
Large I:E ratio (1:5 up to 1:8)
Don‟t worry about CO2/acidosis
Keep plateau pressure under 30
24. Trivia
This resident is president of AAEM/RSA, is the youngest 2nd
year, is a country line dancing fiend, loves to shoot guns,
has an amazing ability to NEVER be hungover.
27. Barotrauma, Breathstacking,
Decreased Venous Return, DEATH
Fluid bolus 1-2L
d/c ET tube
If O2 sat is >88% manually press on chest for about 60
sec
Bilateral needle decompressions and chest tubes. DO
NOT WAIT FOR X-RAY
28. Summary
Β2 agonists, ipratropium, steroids
Magnesium, IV epinephrine, NIPPV
Intubate using lidocaine, ketamine, paralytic
Low PEEP, low TV, long I:E ration, low RR, watch plateau
pressure
If pt arrests think barotrauma: d/c ET tube, b/l
needles/CT
29. Resources
The NNT
Cochrane Review
EM:RAP “The Crashing Asthmatic” April 2007
FOAM:
http://emergencymedicineireland.com/2013/05/the-
crashing-asthmatic/
30. Last Trivia
This resident is the most socially awkward of the second
years, often doesn‟t know what to do with her hands, also
went to the best medical school in the country, and is
thankful to finally made it through an intern year!