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Life-threatening Asthma: Focus on Lung Protection

  • H. Quiroz Martínez
  • N. D. Ferguson
Conference paper

Abstract

Acute asthma exacerbation is a common medical emergency; approximately 10% of asthma related hospital admissions will require intensive care and, despite aggressive medical therapy, 4% will develop life-threatening asthma requiring endotracheal intubation and mechanical ventilation for persistent respiratory failure. Not surprisingly, patients with life-threatening asthma have high morbidity and mortality. In this chapter, we will review the pathophysiology of dynamic hyperinflation and respiratory failure in asthma, and armed with this knowledge we describe how to provide lung protective mechanical ventilation while delivering adequate oxygenation and maximizing medical therapy. We will also comment on the different rescue therapies available for patients with refractory respiratory failure who fail mechanical ventilation.

Keywords

Continuous Positive Airway Pressure Functional Residual Capacity Acute Asthma Noninvasive Positive Pressure 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.

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References

  1. 1.
    Krishnan V, Diette GB, Rand CS, et al (2006) Mortality in patients hospitalized for asthma exacerbations in the United States. Am J Respir Crit Care Med 174: 633–638CrossRefPubMedGoogle Scholar
  2. 2.
    Anzueto A, Frutos-Vivar F, Esteban A, et al (2004) Incidence, risk factors and outcome of barotrauma in mechanically ventilated patients. Intensive Care Med 30: 612–619CrossRefPubMedGoogle Scholar
  3. 3.
    Mansel JK, Stogner SW, Petrini MF, Norman JR (1990) Mechanical ventilation in patients with acute severe asthma. Am J Med 89: 42–48CrossRefPubMedGoogle Scholar
  4. 4.
    Gupta D, Keogh B, Chung KF, et al (2004) Characteristics and outcome for admissions to adult, general critical care units with acute severe asthma: a secondary analysis of the ICNARC Case Mix Programme Database. Crit Care 8: R112–121CrossRefPubMedGoogle Scholar
  5. 5.
    McFadden ER Jr (2003) Acute severe asthma. Am J Respir Crit Care Med 168: 740–759CrossRefPubMedGoogle Scholar
  6. 6.
    National Asthma Education and Prevention Program (2007) Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol 120: S94–138CrossRefGoogle Scholar
  7. 7.
    McFadden ER Jr, Warren EL (1997) Observations on asthma mortality. Ann Intern Med 127: 142–147PubMedGoogle Scholar
  8. 8.
    Eisner MD, Lieu TA, Chi F, et al (2001) Beta agonists, inhaled steroids, and the risk of intensive care unit admission for asthma. Eur Respir J 17: 233–240CrossRefPubMedGoogle Scholar
  9. 9.
    Turner MO, Noertjojo K, Vedal S, Bai T, Crump S, Fitzgerald JM (1998) Risk factors for nearfatal asthma. A case-control study in hospitalized patients with asthma. Am J Respir Crit Care Med 157: 1804–1809PubMedGoogle Scholar
  10. 10.
    Dhuper S, Maggiore D, Chung V, Shim C (2003) Profile of near-fatal asthma in an inner-city hospital. Chest 124: 1880–1884CrossRefPubMedGoogle Scholar
  11. 11.
    Marquette CH, Saulnier F, Leroy O, et al (1992) Long-term prognosis of near-fatal asthma. A 6-year follow-up study of 145 asthmatic patients who underwent mechanical ventilation for a near-fatal attack of asthma. Am Rev Respir Dis 146: 76–81PubMedGoogle Scholar
  12. 12.
    Becker JM, Rogers J, Rossini G, Mirchandani H, D’Alonzo GE Jr (2004) Asthma deaths during sports: report of a 7-year experience. J Allergy Clin Immunol 113: 264–267CrossRefPubMedGoogle Scholar
  13. 13.
    Levine M, Iliescu ME, Margellos-Anast H, Estarziau M, Ansell DA (2005) The effects of cocaine and heroin use on intubation rates and hospital utilization in patients with acute asthma exacerbations. Chest 128: 1951–1957CrossRefPubMedGoogle Scholar
  14. 14.
    Tan WC, Xiang X, Qiu D, Ng TP, Lam SF, Hegele RG (2003) Epidemiology of respiratory viruses in patients hospitalized with near-fatal asthma, acute exacerbations of asthma, or chronic obstructive pulmonary disease. Am J Med 115: 272–277CrossRefPubMedGoogle Scholar
  15. 15.
    de Magalhaes Simoes S, dos Santos MA, da Silva Oliveira M, et al (2005) Inflammatory cell mapping of the respiratory tract in fatal asthma. Clin Exp Allergy 35: 602–611CrossRefPubMedGoogle Scholar
  16. 16.
    James AL, Elliot JG, Abramson MJ, Walters EH (2005) Time to death, airway wall inflammation and remodelling in fatal asthma. Eur Respir J 26: 429–434CrossRefPubMedGoogle Scholar
  17. 17.
    McCarthy DS, Sigurdson M (1980) Lung elastic recoil and reduced airflow in clinically stable asthma. Thorax 35: 298–302CrossRefPubMedGoogle Scholar
  18. 18.
    Cormier Y, Lecours R, Legris C (1990) Mechanisms of hyperinflation in asthma. Eur Respir J 3: 619–624PubMedGoogle Scholar
  19. 19.
    Collett PW, Brancatisano T, Engel LA (1983) Changes in the glottic aperture during bronchial asthma. Am Rev Respir Dis 128: 719–723PubMedGoogle Scholar
  20. 20.
    Peress L, Sybrecht G, Macklem PT (1976) The mechanism of increase in total lung capacity during acute asthma. Am J Med 61: 165–169CrossRefPubMedGoogle Scholar
  21. 21.
    Pepe PE, Marini JJ (1982) Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction: the auto-PEEP effect. Am Rev Respir Dis 126: 166–170PubMedGoogle Scholar
  22. 22.
    Harris RS, Winkler T, Tgavalekos N, et al (2006) Regional pulmonary perfusion, inflation, and ventilation defects in bronchoconstricted patients with asthma. Am J Respir Crit Care Med 174: 245–253CrossRefPubMedGoogle Scholar
  23. 23.
    Tuxen DV, Lane S (1987) The effects of ventilatory pattern on hyperinflation, airway pressures, and circulation in mechanical ventilation of patients with severe air-flow obstruction. Am Rev Respir Dis 136: 872–879PubMedGoogle Scholar
  24. 24.
    Rodrigo GJ, Rodrigo C, Hall JB (2004) Acute asthma in adults: a review. Chest 125: 1081–1102CrossRefPubMedGoogle Scholar
  25. 25.
    Shapiro JM (2002) Management of respiratory failure in status asthmaticus. Am J Respir Med 1: 409–416PubMedGoogle Scholar
  26. 26.
    Martin JG, Shore S, Engel LA (1982) Effect of continuous positive airway pressure on respiratory mechanics and pattern of breathing in induced asthma. Am Rev Respir Dis 126: 812–817PubMedGoogle Scholar
  27. 27.
    Shivaram U, Miro AM, Cash ME, Finch PJ, Heurich AE, Kamholz SL (1993) Cardiopulmonary responses to continuous positive airway pressure in acute asthma. J Crit Care 8: 87–92CrossRefPubMedGoogle Scholar
  28. 28.
    Fernandez MM, Villagra A, Blanch L, Fernandez R (2001) Non-invasive mechanical ventilation in status asthmaticus. Intensive Care Med 27: 486–492CrossRefPubMedGoogle Scholar
  29. 29.
    Meduri GU, Cook TR, Turner RE, Cohen M, Leeper KV (1996) Noninvasive positive pressure ventilation in status asthmaticus. Chest 110: 767–774CrossRefPubMedGoogle Scholar
  30. 30.
    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: 1018–1025CrossRefPubMedGoogle Scholar
  31. 31.
    Ram FS, Wellington S, Rowe B, Wedzicha JA (2005) Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev CD004360Google Scholar
  32. 32.
    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
  33. 33.
    Kollef MH (1992) Lung hyperinflation caused by inappropriate ventilation resulting in electromechanical dissociation: a case report. Heart Lung 21: 74–77PubMedGoogle Scholar
  34. 34.
    Darioli R, Perret C (1984) Mechanical controlled hypoventilation in status asthmaticus. Am Rev Respir Dis 129: 385–387PubMedGoogle Scholar
  35. 35.
    Bidani A, Tzouanakis AE, Cardenas VJ Jr, Zwischenberger JB (1994) Permissive hypercapnia in acute respiratory failure. JAMA 272: 957–962CrossRefPubMedGoogle Scholar
  36. 36.
    Tuxen DV (1994) Permissive hypercapnic ventilation. Am J Respir Crit Care Med 150: 870–874PubMedGoogle Scholar
  37. 37.
    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: 1542–1545CrossRefPubMedGoogle Scholar
  38. 38.
    Smith TC, Marini JJ (1988) Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction. J Appl Physiol 65: 1488–1499PubMedGoogle Scholar
  39. 39.
    Tan IK, Bhatt SB, Tam YH, Oh TE (1993) Effects of PEEP on dynamic hyperinflation in patients with airflow limitation. Br J Anaesth 70: 267–272CrossRefPubMedGoogle Scholar
  40. 40.
    Caramez MP, Borges JB, Tucci MR, et al (2005) Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation. Crit Care Med 33: 1519–1528CrossRefPubMedGoogle Scholar
  41. 41.
    Williams TJ, 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
  42. 42.
    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: 541–546CrossRefPubMedGoogle Scholar
  43. 43.
    Hemming A, MacKenzie I, Finfer S (1994) Response to ketamine in status asthmaticus resistant to maximal medical treatment. Thorax 49: 90–91CrossRefPubMedGoogle Scholar
  44. 44.
    Maltais F, Sovilj M, Goldberg P, Gottfried SB (1994) Respiratory mechanics in status asthmaticus. Effects of inhalational anesthesia. Chest 106: 1401–1406CrossRefPubMedGoogle Scholar
  45. 45.
    Mutlu GM, Factor P, Schwartz DE, Sznajder JI (2002) Severe status asthmaticus: management with permissive hypercapnia and inhalation anesthesia. Crit Care Med 30: 477–480CrossRefPubMedGoogle Scholar
  46. 46.
    Saulnier FF, Durocher AV, Deturck RA, Lefebvre MC, Wattel FE (1990) Respiratory and hemodynamic effects of halothane in status asthmaticus. Intensive Care Med 16: 104–107CrossRefPubMedGoogle Scholar
  47. 47.
    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: 891–896CrossRefPubMedGoogle Scholar
  48. 48.
    Elliot SC, Paramasivam K, Oram J, Bodenham AR, Howell SJ, Mallick A (2007) Pumpless extracorporeal carbon dioxide removal for life-threatening asthma. Crit Care Med 35: 945–948CrossRefPubMedGoogle Scholar
  49. 49.
    Kukita I, Okamoto K, Sato T, et al (1997) Emergency extracorporeal life support for patients with near-fatal status asthmaticus. Am J Emerg Med 15: 566–569CrossRefPubMedGoogle Scholar
  50. 50.
    Shapiro MB, Kleaveland AC, Bartlett RH (1993) Extracorporeal life support for status asthmaticus. Chest 103: 1651–1654CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2009

Authors and Affiliations

  • H. Quiroz Martínez
    • 1
  • N. D. Ferguson
    • 1
  1. 1.Interdepartmental Division of Critical CareToronto Western HospitalTorontoCanada

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