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© The Board of Management and Trustees of the British Journal of Anaesthesia [2008]. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Management of life-threatening asthma in adults
Specialist Registrar in Anaesthesia and Intensive Care
Queen Elizabeth Hospital
Edgbaston
Birmingham B15 2TH
UK
Consultant in Respiratory and Intensive Care Medicine
Queen Elizabeth Hospital
Edgbaston
Birmingham B15 2TH
UK
Tel: +44 121 6271627 Fax: +44 121 6978291E-mail: bill.tunnicliffe@uhb.nhs.uk
Key Words: The primary pathophysiological problem in life-threatening asthma is expiratory gas-flow limitation. • Always be wary of normocapnia and consider it in clinical context; it may be a sign of patient deterioration or exhaustion. • Initiation of invasive ventilation is a clinical decision. • The safety of permissive hypercapnia is well established. Striving for normocapnia is likely to produce significant morbidity.
| The first 150 words of the full text of this article appear below. |
Asthma is a disease of predominantly reversible airway obstruction characterized by a triad of bronchial smooth muscle contraction, airway inflammation, and increased secretions; it is a major health problem for all age groups. For the majority, control of asthma symptoms is readily achieved; however, in a small minority, asthma may cause death. Although the mortality rate for asthma in those aged less than 65 yrs is now falling, there remain around 1400 asthma deaths in the UK each year (http://www.laia.ac.uk/kf_asthma_03.htm). Most of these occur in the pre-hospital setting and, in retrospect, the majority is considered potentially preventable. Factors associated with asthma death include disease severity, inadequate treatment, inadequate monitoring, the under use of written asthma management plans and adverse psychosocial and behavioural factors (www.sign.ac.uk/guidelines/fulltext/63/index.html).
Levels of severity of acute asthma exacerbations have been defined. The features of acute severe, life–threatening, and near fatal asthma are listed
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Pathophysiology |
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Management of life-threatening asthma |
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Initial management
Oxygen
Nebulized β2 agonists
Nebulized ipratropium bromide
Steroids
Intravenous magnesium sulphate
Intravenous bronchodilators
Epinephrine
Mechanical ventilation
Who should be intubated, and when and how should mechanical ventilation be initiated?
What are the initial goals of mechanical ventilation and how are they achieved?
Management of hypercarbia
Ongoing ventilatory management
Additional management methods
Inhalational anaesthetic agents
Extra-corporeal support
Bronchoscopy
Antibiotics
Non-Invasive ventilation
Heliox
Leukotriene antagonists
Monoclonal anti-IgE antibodies