Mechanical ventilation in patients with acute severe asthma

doi:10.1016/0002-9343(90)90096-V

The American Journal of Medicine

Volume 89, Issue 1, July 1990, Pages 42-48

https://doi.org/10.1016/0002-9343(90)90096-V Get rights and content

Abstract

purpose: Acute respiratory failure necessitating intubation and mechanical ventilation in patients with acute severer asthma is relatively uncommon, and there are few data available regarding positive pressure ventilation in critically ill patients with asthma. We therefore decided to evaluate our experience with the use of mechanical ventilation for acute asthma and to critically review previous reports on this subject.

patietns and methods: A retrospective analysis of all medical records of patients who required mechanical ventilation for acute severe asthma was performed for the period of 1980 to 1988. Various clinical parameters were reviewed and examined via Fisher's exact test for association with survival.

results: Twenty-seven patients who underwent ventilation for a total of 32 episodes of mechanical ventilation comprised our study group. The overall mortality was 22%. A total of 76 complications were documented, including six episodes of baro-trauma. The mean duration of artificial ventilation was 114 hours for nonsurvivors and 77 hours for survivors (p <0.05).

conclusion: Although there appears to be a trend toward increased survival after mechanical ventilation for acute asthma, ventilation of critically ill asthmatic patients continues to be a potentially perilous ventures associated with significant morbidity and mortality.

References (45)

CE Robertson et al.
Use of ether in life-threatening acute severe asthma
Lancet
(1985)
FJ Delatorre et al.
Incidence of pneumothorax and pneumomediastinum in patients with aspiration pneumonia requiring ventilatory support
Chest
(1977)
M Steier et al.
Pneumothorax complicating continuous ventilatory support
J Thorac Cardiovasc Surg
(1974)
CW Zwillich et al.
Complications of assisted ventilation
Am J Med
(1974)
MC Rashkin et al.
Acute complications of endotracheal intubation
Chest
(1986)
DE Westerman et al.
Identification of the high risk ashtmatic patient
WR Summer
Status asthmaticus
Chest
(1985)
R Evans et al.
National trends in the morbidity and mortality of asthma in the US
Chest
(1987)
R Dales et al.
Use of mechanical ventilation in adults with severe asthma
Can Med Assoc J
(1984)
C Scoggin et al.
Status asthmaticus: a nine-year experience
JAMA
(1977)

G Gleich et al.

Eosinophils and bronchial inflammation

J-P Derenne et al.

Acute respiratory failure of chronic obstructive pulmonary disease

Am Rev Respir Dis

(1988)

L Zocchi et al.

Effect of hyperinflation and equalization of abdominal pressure on diaphragmatic action

J Appl Physiol

(1987)

E Bondi et al.

Severe asthma: course and treatment in hospital

NY State J Med

(1977)

R Mountain et al.

Clinical features and outcomes in patients with acute asthma presenting with hypercapnia

Am Rev Respir Dis

(1988)

J Fine et al.

Fatal and severe asthma

N Levin et al.

Status asthmaticus and pancuronium bromide

JAMA

(1972)

A Webb et al.

Severe bronchial asthma requiring ventilation

EUM Iisalo et al.

Prolonged artificial ventilation in severe status asthmaticus

Acta Med Scand

(1969)

B Higgins et al.

Assisted ventilation in severe acute asthma

Thorax

(1986)

J Qvist et al.

High-level PEEP in severe asthma

N Engl J Med

(1982)

J Marini

Should PEEP be used in airflow obstruction (editorial)?

Am Rev Respir Dis

(1989)

Cited by (85)

Hypocapnia and Hypercapnia
2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition
Early administration of terbutaline in severe pediatric asthma may reduce incidence of acute respiratory failure
2014, Annals of Allergy, Asthma and Immunology
Citation Excerpt :
Inhaled β agonist therapy and systemic administration of corticosteroids continue to be the treatment of choice for acute asthma exacerbations.11–16 However, despite this therapy, some pediatric patients deteriorate to an acute respiratory failure status and require invasive or noninvasive mechanical ventilation (bilevel positive airway pressure).17–21 One explanation for such an occurrence is based on the fact that severe bronchospasm does not allow sufficient inhaled medication to be topically effective.
Severe pediatric asthma, if not immediately and aggressively treated, may progress to acute respiratory failure requiring mechanical ventilation in the pediatric intensive care unit (PICU). Intravenous (IV) terbutaline, a β₂ agonist, is dispensed when the initial treatment does not improve the clinical condition.
To investigate the influence of early initiation of IV terbutaline on the incidence of acute respiratory failure requiring mechanical ventilation in severe pediatric asthma.
A retrospective chart review was conducted of 120 subjects (35 patients from an outside hospital emergency department [ED] with late start of terbutaline and 85 patients from the authors' hospital ED with early initiation of IV terbutaline) admitted to the PICU with severe asthma treated with continuous IV terbutaline. Responses to terbutaline treatment and outcomes were evaluated.
Patients transported from outlying hospital EDs had shorter pre-PICU mean durations of IV terbutaline than those transferred from the authors' ED (0.69 ± 1.38 and 2.91 ± 2.47 hours, respectively, P = .001). Twenty-one of 35 patients (60%) from outlying EDs required mechanical ventilation compared with 14 of 85 patients (16%) from the authors' ED (P = .001). Durations of pre-PICU terbutaline infusion for patients requiring mechanical ventilation were significantly shorter than those with no such requirement (P = .015).
The results of the present study, conducted in the largest number of subjects to date, suggest that early administration of continuous terbutaline in the ED may decrease acute respiratory failure and the need for mechanical respiratory (invasive and noninvasive) support in severe pediatric asthma.
Acute severe asthma
2013, Oh's Intensive Care Manual, Seventh Edition
Status asthmaticus in the medical intensive care unit: A 30-year experience
2012, Respiratory Medicine
Citation Excerpt :
Most investigators report mortality rates of 6–38% with more recent studies reporting mortality less than 10%.7,8 Several reports suggest that mechanical ventilation (MV) in SA is associated with significant morbidity and mortality.9–12 Many patients admitted with SA will require ICU level care.
To investigate the characteristics, trends in management (permissive hypercapnia; mechanical ventilation (MV); neuromuscular blockade) and their impact on complications and outcomes in Status Asthmaticus (SA).
We performed a retrospective observational study of subjects admitted with SA to a single multidisciplinary MICU over a 30-year period. All laboratory, radiologic, respiratory care, physician notes and orders were extracted from an electronic medical record (EMR) maintained during the entire duration of the study.
Two hundred and twenty-seven subjects were admitted with 280 episodes of SA. While subjects reflected our regional population (52% Hispanic), African Americans were over-represented (22%) and Caucasians under-represented (21%). Thirty-eight percent reported childhood asthma, 27% were steroid dependent (10% in the last 10 years), and 18% had a recent steroid taper. One hundred and thirty-nine (61.2%) required intubation. The duration of hospitalization was similar between mechanically ventilated and non-ventilated subjects (5.8 ± 4.41 vs. 6.8 ± 7.22 days; p = 0.07). The overall complication rate remained low irrespective of the use of permissive hypercapnia or mode of mechanical ventilation (overall mortality 0.4%; pneumothorax 2.5%; pneumonia 2.9%). The frequency of SA declined significantly in the last 10 years of the study (12.4 vs. 3.2 cases/year).
Despite the frequent use of mechanical ventilation, mortality/complication rates remained extremely low. MV did not significantly increase the duration of hospitalization. At our institution, the frequency of SA significantly decreased despite an increase in emergency room visits for asthma.
Ventilator support
2009, Asthma and COPD
When severe hypoxemia develops in patients with asthma and chronic obstructive pulmonary disease (COPD), intubation and mechanical ventilation may be necessary to ensure the delivery of a sufficiently high fractional inspired oxygen concentration. An increase in work of breathing, secondary to an increase in airway resistance or an inspiratory threshold load associated with auto-positive end-expiratory pressure or intrinsic positive end-expiratory pressure, often requires mechanical ventilation to rest the respiratory muscles and decrease the oxygen cost of breathing. The term mode refers to the relationship among various breath types such as, mandatory, assisted, supported, spontaneous, and inspiratory phase variables. Studies have established that it is possible to achieve satisfactory bronchodilation using a metered-dose inhaler (MDI) despite the presence of an endotracheal tube in mechanically ventilated patients. It is essential to follow a specified protocol, use an inline chamber device, and actuate the MDI at the onset of inspiratory airflow. Patients receiving mechanical ventilation are at risk of numerous complications, including oxygen toxicity, air leaks, infection, endotracheal tube complications, and decreased cardiac output. These problems occur frequently and they can be life threatening if not promptly detected and treated. Abnormalities in pulmonary gas exchange, lung mechanics, and respiratory muscle function contribute to the development of respiratory failure. Adapting ventilator strategies that account for these abnormalities, such as controlled hypoventilation in acute asthma or the application of external PEEP in patients with COPD, may decrease morbidity and possibly improve patient outcome.
Ventilator Support
2008, Asthma and COPD: Basic Mechanisms and Clinical Management
When severe hypoxemia develops in patients with asthma and chronic obstructive pulmonary disease (COPD), intubation and mechanical ventilation may be necessary to ensure the delivery of a sufficiently high fractional inspired oxygen concentration. An increase in work of breathing, secondary to an increase in airway resistance or an inspiratory threshold load associated with auto-positive end-expiratory pressure or intrinsic positive end-expiratory pressure, often requires mechanical ventilation to rest the respiratory muscles and decrease the oxygen cost of breathing. The term mode refers to the relationship among various breath types such as, mandatory, assisted, supported, spontaneous, and inspiratory phase variables. Studies have established that it is possible to achieve satisfactory bronchodilation using a metered-dose inhaler (MDI) despite the presence of an endotracheal tube in mechanically ventilated patients. It is essential to follow a specified protocol, use an inline chamber device, and actuate the MDI at the onset of inspiratory airflow. Patients receiving mechanical ventilation are at risk of numerous complications, including oxygen toxicity, air leaks, infection, endotracheal tube complications, and decreased cardiac output. These problems occur frequently and they can be life threatening if not promptly detected and treated. Abnormalities in pulmonary gas exchange, lung mechanics, and respiratory muscle function contribute to the development of respiratory failure. Adapting ventilator strategies that account for these abnormalities, such as controlled hypoventilation in acute asthma or the application of external PEEP in patients with COPD, may decrease morbidity and possibly improve patient outcome.

View all citing articles on Scopus

^∗: Dr. Stogner's current address is Louisiana State University Medical Center, Shreveport, Louisiana.

View full text

Mechanical ventilation in patients with acute severe asthma

Abstract

Lancet

Chest

J Thorac Cardiovasc Surg

Am J Med

Chest

Status asthmaticus

Chest

National trends in the morbidity and mortality of asthma in the US

Chest

Use of mechanical ventilation in adults with severe asthma

Can Med Assoc J

Status asthmaticus: a nine-year experience

JAMA

Eosinophils and bronchial inflammation

Acute respiratory failure of chronic obstructive pulmonary disease

Am Rev Respir Dis

Effect of hyperinflation and equalization of abdominal pressure on diaphragmatic action

J Appl Physiol

Severe asthma: course and treatment in hospital

NY State J Med

Clinical features and outcomes in patients with acute asthma presenting with hypercapnia

Am Rev Respir Dis

Fatal and severe asthma

Status asthmaticus and pancuronium bromide

JAMA

Severe bronchial asthma requiring ventilation

Prolonged artificial ventilation in severe status asthmaticus

Acta Med Scand

Assisted ventilation in severe acute asthma

Thorax

High-level PEEP in severe asthma

N Engl J Med

Should PEEP be used in airflow obstruction (editorial)?

Am Rev Respir Dis