Mechanical Ventilation for Acute Asthma Exacerbations

  • D. De Mendoza
  • M. Lujan
  • J. Rello
Conference paper


The prevalence and incidence of asthma are high in the Western world, and increasing in developing countries [1]. The risk of an acute attack increases with poor control of the disease, being greater in patients with low socioeconomic stratus and in patients with poor compliance of treatment. Among those patients suffering an acute exacerbation, the risk of needing intensive care unit (ICU) management ranges from 4 to 7% of all asthma admissions. Mechanical ventilation is required in about 30% of patients admitted to an ICU [2], and it has been estimated that 6,000–10,000 patients require mechanical ventilation for acute asthma in the United States each year [3]. Mortality is low for acute exacerbations, but increases up to 8% when mechanical ventilation is required [4], and as the patients at risk are usually young, the social impact is not depreciable. The risk of death depends on the severity of the attack, with the rapidity of onset of the crisis and the response to treatment being crucial. Most deaths are related to the occurrence of cardiac arrest before reaching medical assistance, caused either by cardiac arrhythmias or by severe airflow limitation and hypoxemia leading to muscle exhaustion and respiratory arrest [5]. Another subset of deaths can be related to inappropriate recognition of the severity of the attack and, thus, to inappropriate management, particularly of the mechanical ventilation. Therefore, early identification of the severity and rapid transfer to an emergency department for early initiation of therapy can prevent morbidity and mortality [5]. Moreover, death must be considered an avoidable event among those patients who reach emergency care. Fast and accurate institution of pharmacologic therapy and especially of endotracheal intubation and mechanical ventilation where necessary is crucial in order to avoid a fatal outcome.


Mechanical Ventilation Tidal Volume Respir Crit Minute Ventilation Status Asthmaticus 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Eder W, Ege MJ, Von Mutius E (2006) The asthma epidemic. N Engl J Med 355:2226–2235PubMedCrossRefGoogle Scholar
  2. 2.
    McFadden ER Jr (2003) Acute severe asthma. Am J Respir Crit Care Med 168:740–759PubMedCrossRefGoogle Scholar
  3. 3.
    Pendergraft TB, Stanford RH, Beasley R, Stempel DA, Roberts C, McLaughlin T (2004) Rates and characteristics of intensive care unit admissions and intubations among asthma-related hospitalizations. Ann Allergy Asthma Inmunol 93:29–35Google Scholar
  4. 4.
    Afessa B, Morales I, Cury JD (2001) Clinical course and outcome of patients admitted to an ICU for status asthmaticus. Chest 120;1616–1621PubMedCrossRefGoogle Scholar
  5. 5.
    Rodrigo GJ, Rodrigo C, Hall JB(2004) Acute asthma in adults: A review. Chest 125:1081–1102PubMedCrossRefGoogle Scholar
  6. 6.
    Blanch L, Bernabe F, Lucangelo U (2005) Measurement of air trapping, intrinsic positive end-expiratory pressure, and dynamic hyperinflation in mechanically ventilated patients. Respir Care 50:110–123PubMedGoogle Scholar
  7. 7.
    Tuxen DV, Williams TJ, Scheinkestel CD, Czarny D, Bowes G (1992) Use of a measurement of pulmonary hyperinflation to control the level of mechanical ventilation in patients with acute severe asthma. Am Rev Respir Dis 146:1136–1142PubMedGoogle Scholar
  8. 8.
    Williams DJ, Tuxen DV, Scheinkestel CD, Czarny D, Bowes G (1992) Risk factors for morbidity in mechanically ventilated patients with acute severe asthma. Am Rev Respir Dis 146: 607–615PubMedGoogle Scholar
  9. 9.
    Rodriguez-Roisin R (1997) Acute severe asthma: pathophysiology and pathobiology of gas exchange abnormalities. Eur Respir J 10:1359–1371PubMedCrossRefGoogle Scholar
  10. 10.
    Rosengarten PL, Tuxen DV, Dziukas L, Scheinkestel C, Merrett K, Bowes G (1991) Circulatory arrest induced by intermittent positive-pressure ventilation in a patient with severe asthma. Anaesth Intensive Care 19:118–121PubMedGoogle Scholar
  11. 11.
    Lisboa T, de Mendoza D, Rello J (2007) A woman with asthma and cardiorespiratory arrest. N Engl J Med 357:420Google Scholar
  12. 12.
    Phipps P, Garrard CS (2003) The pulmonary physician in critical care: 12. Acute severe asthma in the intensive care unit. Thorax 58:81–88PubMedCrossRefGoogle Scholar
  13. 13.
    Eames WO, Rooke GA, Wu RS, Bishop MJ (1996) Comparison of the effects of etomidate, propofol and thiopental on respiratory resistance after tracheal intubation. Anesthesiology 84:1307–1311PubMedCrossRefGoogle Scholar
  14. 14.
    Malerba G, Romano-Girard F, Cravoisy A, et al (2005) Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation. Intensive Care Med 31:388–392PubMedCrossRefGoogle Scholar
  15. 15.
    Eason J, Tayler D, Cottam S, et al (1991) Manual chest compression for total bronchospasm. Lancet 337:366PubMedCrossRefGoogle Scholar
  16. 16.
    Tuxen DV, Lane S (1987) The effects of ventilatory pattern on hyperinflation, airway pressures, and circulation in mechanical ventilation of patients with severe airflow obstruction. Am Rev Respir Dis 136:872–879PubMedGoogle Scholar
  17. 17.
    Leatherman JW, McArthur C, Shapiro RS (2004) Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Crit Care Med 32:1542–1545PubMedCrossRefGoogle Scholar
  18. 18.
    Oddo M, Feihl F, Schaller M-D, Perret C (2006) Management of mechanical ventilation in acute severe asthma: Practical aspects. Intensive Care Med 32:501–510PubMedCrossRefGoogle Scholar
  19. 19.
    Leatherman JW, Ravenscraft SA (1996) Low measured auto-positive end-expiratory pressure during mechanical ventilation of patients with severe asthma: Hidden auto-positive end-expiratory pressure. Crit Care Med 24:541–546PubMedCrossRefGoogle Scholar
  20. 20.
    Leatherman JW (2006) Mechanical ventilation for severe asthma. In: Tobin MJ (ed) Principles and Practice of Mechanical Ventilation. Second edition. McGraw-Hill, New York, pp 649–662Google Scholar
  21. 21.
    Feihl F, Perret C (1994) Permissive hypercapnia: How permissive should we be? Am J Respir Crit Care Med 150:1722–1737PubMedGoogle Scholar
  22. 22.
    Cardenas VJ Jr, Zwischenberger JB, Tao W, et al (1996) Correction of blood pH attenuates changes in hemodynamics and organ blood flow during permissive hypercapnia. Crit Care Med 24:827–834PubMedCrossRefGoogle Scholar
  23. 23.
    Bellomo R, McLaughlin P, Tai E, Parkin G (1994) Asthma requiring mechanical ventilation: a low-morbidity approach. Chest 105:891–896PubMedCrossRefGoogle Scholar
  24. 24.
    Griffin D, Fairman N, Coursin D, Rawsthorne L, Grossman JE (1992) Acute myopathy during treatment of status asthmaticus with corticosteroids and steroidal muscle relaxants Chest 102:510–514PubMedCrossRefGoogle Scholar
  25. 25.
    Leatherman JW, Fluegel WL, David WS, Davies SF, Iber C (1996) Muscle weakness in mechanically ventilated patients with severe asthma. Am J Respir Crit Care Med 153:1686–1690PubMedGoogle Scholar
  26. 26.
    Behbehani NA, Al-Mane F, D’yachkova Y, Pare P, FitzGerald JM (1999) Myopathy following mechanical ventilation for acute severe asthma: The role of muscle relaxants and corticosteroids. Chest 115:1627–1631PubMedCrossRefGoogle Scholar
  27. 27.
    Stevens RD, Dowdy DW, Michaels RK, Mendez-Tellez PA, Pronovost PJ, Needham DM (2007) Neuromuscular dysfunction acquired in critical illness: a systematic review. Intensive Care Med 33:1876–1891PubMedCrossRefGoogle Scholar
  28. 28.
    Dhand R, Tobin MJ (1997) Inhaled bronchodilator therapy in mechanically ventilated patients. Am J Respir Crit Care Med 156:3–10PubMedGoogle Scholar
  29. 29.
    Thomas SH, O’Doherty MJ, Fidler HM, Page CJ, Treacher DF, Nunan TO (1993) Pulmonary deposition of a nebulised aerosol during mechanical ventilation. Thorax 48:154–159PubMedCrossRefGoogle Scholar
  30. 30.
    Lange CF, Finaly WH (2000) Overcoming the adverse effect of humidity in aerosol delivery via pressurized metered-dose inhalers during mechanical ventilation. Am J Respir Crit Care Med 161:1614–1618PubMedGoogle Scholar
  31. 31.
    Antonelli M, Conti G, Rocco M, et al (1998) A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 339:429–435PubMedCrossRefGoogle Scholar
  32. 32.
    Meduri GU, Cook TR, Turner RE, Cohen M, Leeper KV (1996) Noninvasive positive pressure ventilation in status asthmaticus. Chest 110:767–774PubMedCrossRefGoogle Scholar
  33. 33.
    Fernandez MM, Villagra A, Blanch L, Fernandez R. (2001) Non-invasive mechanical ventilation in status asthmaticus. Intensive Care Med 27:486–492PubMedCrossRefGoogle Scholar
  34. 34.
    Soroksky A, Stav D, Shpirer I (2003) A pilot prospective, randomized, placebo-controlled trial of bilevel positive airway pressure in acute asthmatic attack. Chest 123:1018–1025PubMedCrossRefGoogle Scholar
  35. 35.
    Maltais F, Sovilj M, Goldberg P, Gottfried SB (1994) Respiratory mechanics in status asthmaticus: Effects of inhalational anesthesia. Chest 106:1401–1406PubMedCrossRefGoogle Scholar
  36. 36.
    Rooke GA, Choi JH, Bishop MJ (1997) The effect of isoflurane, halothane, sevoflurane, and thiopental/nitrous oxide on respiratory system resistance after tracheal intubation. Anesthesiology 86:1294–1299PubMedCrossRefGoogle Scholar
  37. 37.
    Maltais F, Reissmann H, Navalesi P, et al (1994) Comparison of static and dynamic measurements of intrinsic PEEP in mechanically ventilated patients. Am J Respir Crit Care Med 150:1318–1324PubMedGoogle Scholar
  38. 38.
    Reuben AD, Harris AR (2004) Heliox for asthma in the emergency department: A review of the literature. Emerg Med J 21:131–135PubMedCrossRefGoogle Scholar
  39. 39.
    Gluck EH, Onorato DJ, Castriotta R (1990) Helium-oxygen mistures in intubated patients with status asthmaticus and respiratory acidosis. Chest 98:693–698PubMedCrossRefGoogle Scholar
  40. 40.
    Schaeffer EM, Pohlman A, Morgan S, Hall JB (1999) Oxygenation in status asthmaticus improves during ventilation with helium-oxygen. Crit Care Med 27:2666–2670PubMedCrossRefGoogle Scholar
  41. 41.
    Rodrigo GJ, Rodrigo C, Pollack CV, Rowe B (2003) Use of helium-oxygen mixtures in the treatment of acute asthma: A systematic review. Chest 123:891–896PubMedCrossRefGoogle Scholar
  42. 42.
    Tassaux D, Jolliet P, Thouret JM, Roeseler J, Dorne R, Chevrolet JC (1999) Calibration of seven ICU ventilators for mechanical ventilation with helium-oxygen mixtures. Am J Respir Crit Care Med 160:22–32PubMedGoogle Scholar
  43. 43.
    Lang DM, Simon RA, Mathison DA, Timms RM, Stevenson DD (1991) Safety and possible efficacy of fiberoptic bronchoscopy with lavage in the management of refractory asthma with mucous impactation. Ann Allergy 67:324–330PubMedGoogle Scholar
  44. 44.
    Shapiro MB, Kleaveland AC, Bartlett RH (1993) Extracorporeal life support for status asthmaticus. Chest 103:1651–1654PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media Inc. 2008

Authors and Affiliations

  • D. De Mendoza
    • 1
  • M. Lujan
    • 2
  • J. Rello
    • 1
  1. 1.Critical Care DepartmentJoan XXIII University HospitalTarragonaSpain
  2. 2.Department of PneumologyCorporacio Sanitaria Parc TauliSabadellSpain

Personalised recommendations