Ep 193 The Crashing Asthmatic – Recognition and Management of Life Threatening Asthma

In part 1 of this 2-part podcast series on asthma with Dr. Leeor Sommer and Dr. Sameer Mal we covered asthma mimics, risk stratification, ED treatment and who is safe to go home. We drove home that there are many important details in risk stratifying these patients, making sure they are on the right medications, and good discharge instructions to avoid bounce backs and morbidity. In this part 2, we dig into the recognition and management of the crashing asthmatic. We answer such questions as: what are the key elements in recognition of threatening asthma? What are the most time-sensitive interventions required to break the vicious cycle of asthma? What are the best options for dosing and administering magnesium sulphate, epinephrine, fentanyl and ketamine in the management of the crashing asthmatic? What is the role of NIPPV in the management of life-threatening asthma? What are the factors we should consider when it comes to indications for endotracheal intubation of the crashing asthmatic? What role do blood gases play in the decision to intubate? What are the most appropriate ventilation strategies in the intubated asthma patient? and many more... Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul Written Summary and blog post by Sara Brade, edited by Anton Helman April, 2024 Cite this podcast as: Helman, A. Sommer, L. Mal, S. The Crashing Asthmatic - Recognition and Management of Life-threatening Asthma. Emergency Medicine Cases. April, 2024. https://emergencymedicinecases.com/crashing-asthmatic-life-threatening-asthma. Accessed September 17, 2024 Résumés EM Cases  Go to part 1 of this 2-part podcast on adult asthma exacerbations Recognition of life-threatening, near fatal asthma * Appearance: Agitated, obtunded, few word dyspnea, accessory muscle use/ tripoding, respiratory arrest * Vitals: hypoxic, increased (>30) or decreased RR, elevated HR (>120), bradycardia indicative of impending arrest * Physical exam: silent chest, biphasic wheeze * Bedside investigations: Peak flow <25% patient’s best (although there is no role for measuring peak flows in the crashing asthmatic) * Clinical course: Suboptimal/worsening response to initial therapies, fatiguing, decreasing LOC Overview: Initial approach to management of the crashing asthmatic Call for help RNs/ RT/ another emerg doc/ ICU/ anaesthesia B – C – A Breathing THEN Circulation THEN Airway Breathing * O2 via NP * Immediate inhaled bronchodilators * Continuous nebulized salbutamol, up to 15 mg/hr * Continuous nebulized ipratropium, up to 1.5mg/hr * IV Methylprednisolone 125 mg * IV Magnesium sulfate 2 g over 10-15 mins, repeat x3; consider IV fluid bolus before giving magnesium because of hypotension risk and to replace insensible losses from asthma * Systemic bronchodilators * IM/IV Epinephrine * IM: 0.3 to 0.5 mg q 20 mins x 1-2 doses * IV: ** preferred over IM ** initial 5 mcg/min, titrate up by 1-15 mcg/min every 2-3 mins, dose range: 0.05 to 0.5 mcg/kg/min, down titrate as soon as able OR * IV Salbutamol