The podcast explores various topics related to asthma management, including initial assessment and diagnosis, treatment options, non-invasive ventilation, importance of steroids, managing auto peep, respiratory acidosis, ketamine for pain management and bronchodilation, challenges of using anesthesia circuit in ICU, and considerations for using ECMO.
Bronchodilators and steroids are essential in the treatment of ICU level asthma, with tailored dosing and administration.
Non-invasive ventilation, like bipap, is an effective strategy for managing non-intubated crashing asthmatic patients.
Intubation should be reserved for patients not responding to non-invasive interventions, with a focus on preventing complications and carefully titrating PEEP.
Deep dives
Main Ideas
1. Diagnosis and initial assessment of asthma patients
2. Non-intubated crashing asthmatic and the physiological circle of death
3. Treatment strategies including bronchodilators, steroids, and epinephrine
4. Importance of avoiding complications like pneumothorax and VAP
Bronchodilators and Steroids
Bronchodilators and steroids are essential in the treatment of ICU level asthma. Inhaled albuterol and ipratropium should be used, along with systemic steroids like methylprednisolone. Epinephrine can be considered for patients who can't tolerate bronchodilators. Dosing and administration should be tailored to individual patient needs and response.
Non-invasive Ventilation
Non-invasive ventilation, like bipap, is an effective strategy for managing non-intubated crashing asthmatic patients. It helps improve dyspnea and gas trapping. Sedation with dexmedetomidine or other agents can be used to facilitate bipap use. Monitoring respiratory rate, tidal volume, and minute ventilation is crucial to ensure effective support.
Intubation and Mechanical Ventilation
Intubation should be reserved for patients who are not responding to non-invasive interventions or experiencing impending respiratory failure. The use of large ET tubes and permissive hypercapnia can be beneficial. Avoid excessive sedation and focus on preventing complications like auto-peep and pneumothorax during mechanical ventilation.
Managing Auto PEEP and Intrinsic PEEP
To manage auto PEEP and intrinsic PEEP in ventilated patients, it is important to measure the intrinsic PEEP accurately using an expiratory hold. To treat auto PEEP and improve exhalation, adjustments can be made to the respiratory rate, tidal volume, or inspiratory time. Matching the applied PEEP to the intrinsic PEEP can aid in weaning the patient from the ventilator. Careful titration of PEEP is necessary to avoid detrimental effects, such as increased plateau pressure and gas trapping.
Optimizing Ventilation in Asthmatics
In asthmatic patients, maintaining a low respiratory rate and reasonable tidal volumes are key to optimizing ventilation. Keeping the respiratory rate around 12 to 14 breaths per minute and the tidal volume at approximately 6 to 8 mL/kg can help prevent dead space ventilation. Avoiding excessive increase in the respiratory rate, even in the presence of elevated PCO2, is important as it can be counterproductive. It is also important to ensure adequate oxygenation without requiring high levels of FiO2, as most asthmatics should primarily have problems with CO2 removal rather than oxygenation.
We know you all have been waiting for it! Here is one of the foundational chapters for the IBCC. All things asthma. We've got everything from physiology, to bleeding edge sedation approaches.
Come take a (longer) listen to solidify everything you read in the post:
-Presentation / patient phenotypes
-Initial management
-Escalation to salvage treatments
-Vent Management & ECMO
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