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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