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Intubation of Asthmatics

Discussion in 'Emergency Medicine' started by step1, Feb 10, 2007.

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  1. step1

    step1 2+ Year Member

    Feb 7, 2007
    Some say this is a failure of medical management. I hear of others using it fairly liberally to get over the steroid hump if medical management/BiPAP isn't working.

    Does your hospital intubate asthmatics? How strict are they regarding this?

    I found it extremely difficult to intubate a decompensated asthmatic where all medical treatments haven't helped enough (then again, not very experienced). Do you hear of Cric's in these cases?

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  3. What was so difficult about tubing a decomp'ed asthmatic? Did you encounter laryngospasm or something else? Did the pt have other factors that would complicate the airway (obesity, no neck, etc)?

    Personally, I would say that in my experience as an RT, we (and the docs we work with) try to avoid tubing an asthmatic at all cost and are often able to avoid this through aggressive use of medications and NPPV. However, about 10-25%* of a given series of asthmatics who need ventilatory support wind up tubed. It really varies from facility to facility based upon the individual preferences of the docs and the types (most prominently along the lines of race and sex) of patients they encounter.....I've noticed that black women and Hispanic males tend to wind up failing an NPPV trial more frequently than others.....but once again this is just my anecdotal opinion at this point in time.

    If they are properly paralyzed and sedated prior to attempting the tube normally there is no more difficulty than any other medical patient without overt distortion of the airway anatomy. That being said, the most common hangups I see, even among relatively experienced docs and RT's is to not wait for the paralytic and sedatives to take full effect. Just my 2 cents.....

    Oh, and I've seen one cric in a crashing asthmatic that I can recall....but that lady was 400+ lbs and there was no way in hell to secure an airway otherwise.

    *Speaking anecdotally, and taking a guess at a percentage from my most recent experiences
  4. mikecwru

    mikecwru M.D. = Massive Debt 7+ Year Member

    Oct 21, 2002
    Hospitals don't intubate asthmatics, doctors do.

    If someone "doesn't intubate asthmatics" they haven't treated enough asthmatics.

    My thoughts on this are: sometimes you have no choice. Remember, you're not intubating for the disease process per se, but for respiratory failure, which is what happens when all other treatments don't work. Sometimes you don't even get to "all treatments." The positive pressure usually works against you, so asthmatics are notoriously a pain to ventilate properly and will often breath stack, but if they're failing, they need to be tubed.

  5. step1

    step1 2+ Year Member

    Feb 7, 2007
    Thank you for your thoughts!

    I do think NPPV before intubation (but appreciate mikecwru's point).

    This patient was some 375lb male- he was adequately sedated, but when I checked the larynx, it was completely swollen and erythematous- no vocal cords to be seen (and made me even wonder if this was asthma and not anaphylaxis, although most family members had histories of being tubed or death from asthma).

    My concern about NPPV:
    I always hear of "Auto-PEEP" with the use of NPPV. I've looked into this but haven't quite understood yet how to look for signs of it. I assume using lower pressures prevents this.

    Patients surprisingly tell me they're happier when NPPV is started (looks uncomfortable)

    Also, in my former hospital, there was often the use of Opiates among Pulm/CC guys: the idea being respiratory suppression to allow an adequate expiratory time for oxygenation (and control of discomfort).
    Anyone use narcotics? I'm searching for articles on this since, although it worked well with patients, it seems odd.

    Thanks :D
  6. BKN

    BKN Senior Member 10+ Year Member

    Oct 31, 2005
    Read Rosen's on severe asthma attacks, it's all there.

    Off the top of my head. About 2% of asthma visits end up in intubation. Besides BiPap, magnesium, SQ terbutalline, and theophylline may help avoid the tube when continuous albuterol, atrovent and steroids have failed.

    Once you decide you must, you may use the usual drugs for intubation, but continuous paralysis is a bad idea. Curariform drugs are after all cholinergics, which cause bronchospasm.

    A tube in your trachea is perhaps the greatest stimulus for bronchospasm. Sedation should be done to allow patients to cooperate with the blower and tolerate the very unpleasant sensation. I would choose benzos rather than opiates, since the latter can cause histamine release and bronchospasm occasionally.

    Vent settings are extremely important to avoid stacking and autopeep. Use small volumes (6 ml/kg) and low rates and adjust the inspiratory/expiratory ratio to allow for exhalation. Ideally the ratio should be about 1:4. Permissive hypercapnia is OK as long as the patient is not hypoxic.

  7. Jeff698

    Jeff698 Chief Resident 10+ Year Member

    Aug 11, 2000
    Salado, Texas
    I think you've identified your airway difficulty right there. He's huge. By his weight alone you can predict that laryngoscopy will likely be a difficult and pucker inducing experience. Intubating almost anyone of this size, regardless of disease process, can be very challenging. The best approach is to assume it will be difficult and plan accordingly. Bring your back up devices to the bedside.

    Take care,
  8. a_ditchdoc

    a_ditchdoc 5+ Year Member

    Apr 17, 2005
    Detroit, Mi
    I've seen Heliox used with good results where everything else failed.
  9. Thank you BKN......you beat me to bringing up permissive hypercapnia and other lung protective ventilation strategies. :thumbup:
  10. Wackie

    Wackie Inappropriate, always 5+ Year Member

    Mar 20, 2006
    Home with the Armadillo
    May I ask why obesity makes intubating more difficult?
  11. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Partner Organization 10+ Year Member

    Nov 18, 2002
    SDN Partner
    I intubate for severe hypoxia (can't keep em over 85% even with NPPV) or for altered mental status or just plain tuckered out. Otherwise, I nervously watch them while throwing the kitchen sink at them....for days if needed. I find things get a lot harder the second you intubate them.
  12. step1

    step1 2+ Year Member

    Feb 7, 2007

    Great comments!

    Would you still use Terbutaline despite giving Albuterol nebs or is this overkill? Also I've heard of oral albuterol-related tablets in the past, does any one use this?

    Someone mentioned "Heliox"... I haven't seen a hospital having this mixture available. Silly Q- is this just using a helium tank and mixing it with an oxygen source? I don't see why this is difficult for hospitals to obtain. Despite its moderate-low effectiveness, it sounds like an inexpensive measure.

    Regarding Hypercapnia: Before intubation, I was told from CC guys not to intubate based on the CO2, even if its high like 80-90.
    But EP's tell me they do intubate based on CO2 levels.

    I would think of checking pO2 levels and looking at the overall condition of the patient to make the call. (Also not a fan of waiting for the patient to nearly code before intubating as I notice some anti-intubation physicians are).

    Last Q: I don't own a Rosen (or Tintinalli), or other major medical text (just came out of a completely different field), and am looking to buy. Any thoughts between the 2 texts?
    (I'm sure this has been brought up in the past and am doing the searches)


    :luck: S1
  13. MasterintuBater

    MasterintuBater Senior Member 10+ Year Member

    Feb 5, 2004
    We use heliox regularly at 70/30 or 80/20. It's real value is in the first 1-2 hours of an acute attack. I used it the other night in a severe croup case as well. Run albuterol/atrovent/racemic epi through the mixture for enhanced delivery. Heliox has unpuckered my sphincter on several occasions.
  14. waterski232002

    waterski232002 Senior Member 5+ Year Member

    Sep 5, 2004
    How many of you guys actually use Terbutaline in adults? I use it in severe asthmatics in peds, but never use it in adults. How about terbutaline gtt's in adults? Anyone ever done that?

    In my short experience, I've found the exact opposite in regard to management of intubating based on pCO2 levels. Medicine and CC docs tend to intubate based on labs, while the ED tends to intubate based on clinical analysis.
  15. Chronic Student

    Chronic Student So Fresh, So Clean 5+ Year Member

    Feb 7, 2006
    Lots of redundant tissue that presses on the airway and its really difficult to lift up all that tissue with the laryngoscope.

    As a general rule, most everything is more difficult with obese patients.

  16. Aloha Kid

    Aloha Kid Senior Member 10+ Year Member

    Mar 9, 2001
    Just had a pretty bad ashmatic the other night.

    1. Nebs, HART nebs
    2. Solumedrol IV
    3. Terbutaline SQ
    4. IV Magnesium

    Did the trick.
  17. BKN

    BKN Senior Member 10+ Year Member

    Oct 31, 2005
    When I'm not sure the neb is getting in (that is really tight airways), the terbutalline works well. I'm old enough to remember when therre were no nebs only SQ first epi then terbutalline.

    I guess the reason that Heliox is not generally available is that it's only moderately effective (at best) and rarely needed.

    Intubating asthmatics should be based on clinical measures: I use lethargy/stupor or the inability to say two words "no tube!"

    If you're gonna be an EP, Rosen's is better. More coverage, more depth. And easier to read than it used to be.
  18. NinerNiner999

    NinerNiner999 Senior Member 10+ Year Member

    Nov 4, 2003
    Where it's at.
    Terbutaline 0.3mg SQ is part of my "Advanced Asthma Management." I give this to patients with h/o intubation, critical care admission, and a severity of >6/10. I'll also throw in Mag for any peak flow less than 175 in adults. Bipap is helpful in 50% of the times in my experience. That said, I think BKN is right on regarding the frequency of ED intubation. I've probably intubated 2-4% of all athmatics I've treated.

    If you do tube, go with Ketamine for sedation - it is indicated for status asthmaticus...

    On a similar topic, patient presents with chest pain, h/o MI, and ongoing asthma exacerbation. EKG shows tachycardia and ischemic changes (no clearcut ST elevation). Do you give steroids?
  19. kungfufishing

    kungfufishing Senior Member 7+ Year Member

    Mar 7, 2003
    Rosen's is "longer" from the standpoint of more pages but is a faster and more informative read.
  20. pushinepi2

    pushinepi2 Bicarb chaser 10+ Year Member

    I absolutely agree with the earlier post... some asthmatics will ultimately require intubation; its a matter of available reserve and fatigue. I think every ED practitioner on this forum would agree that its not difficult to recognize the decompensating asthmatic- these patients speak in truncated sentences, are often diaphoretic, and have a history of intubation/icu admission. Heck, I even met these poor souls during my days as a field medic. Definitely scary.

    Interestingly enough, there's not a lot of evidence based data to definitively lay out a "one plan fits all" for the asthmatic that's circling the drain. Whether you're concerned about auto-peep, acidosis or barotrauma- it matters little in the face of impending respiratory failure. Some people simply need a tube because they can't exhale or are too fatigued to breathe on their own. I'd respectfully suggest that ER people tend to 'throw the book' at the deteriorating asthmatic. I, for one, say, "why not?" to epinephrine. Patients on the verge of intubation put out a bolus of catecholamines that overshadows the short lived physiologic effects of an epi injection. I don't know of any studies comparing subcutaneous terb to epi in terms of outcomes, but there's a paucity of data to suggest that intramuscular meds might be better absorbed. Patients in extremis tend to be peripherally vasoconstricted, and intramuscular catecholamines might be a little more rapidly observed. Mag sulfate should be used liberally- it has little side effects, few medication interactions, and works best in patients with severe bronchospasm. (Even if it achieves bronchodilation in only 50-60 percent of patients!)

    Anyway, here's my non evidenced-based, anecdotal, and entirely subjective algorithm for the severe asthmatic:

    1) Continuous nebs, steroids, fluids
    2) Magnesium sulfate
    3) Consider epinephrine IM or SQ / terbutaline for you
    4) Consider CPAP/BiPAP early or as a bridge to intubation
    5) Heliox
    6) Intubation with ketamine for induction/sedation


    Push in that epi.
  21. leviathan

    leviathan Drinking from the hydrant Moderator Emeritus 10+ Year Member

    Biased opinion! :laugh:
  22. spyderdoc

    spyderdoc Moderator Emeritus Lifetime Donor 10+ Year Member

    Jul 30, 2002
    SF Bay Area
    My few asthmatic intubations have been based entirely on clinical assessment, and they all had the telltale "sweat halo" around them on the bed sheet.....In my intern year, I got scolded for doing an ABG on an asthmatic that I was considering intubating (southerndoc: A.W. in case you were wondering).

    Sedation w/ Ketamine works well for RSI....There was an article in the ANnals to see if Ketamine in low doses is good to prevent intubation, but it doesn't appear to be the case:

    Study objective: To evaluate the efficacy of IV ketamine in the management of acute, severe asthma.

    Methods: This prospective, randomized, double-blind, placebo-controlled clinical trial at an urban teaching hospital emergency department involved 53 consecutive patients aged 18 to 65 with a clinical diagnosis of acute asthmatic exacerbation and a peak expiratory flow of less than 40% of the predicted value after three albuterol nebulizer treatments. All patients received oxygen, continuous nebulized albuterol, and methylprednisolone sodium succinate (Solu-Medrol). Patients then received either ketamine hydrochloride in a bolus of .2 mg/kg followed by IV infusion of .5 mg/kg per hour for 3 hours or a placebo bolus and infusion for 3 hours. Because of the occurrence of dysphoric reactions, the bolus dose was lowered to .1 mg/kg after the first 9 patients; the infusion dose was kept the same.

    Results: The first nine patients were eliminated from analysis. Repeated ANOVA testing on the remaining 44 patients determined significant improvements over time within each treatment group in peak flow (F=3.637, P=.004), Borg score (F=22.959, P=.0001), respiratory rate (F=8.11, P=.0001), and 1-second forced expiratory volume (F=9.076, P=.0001). However, no difference could be detected over time between treatment groups (power, 80%). Patients receiving ketamine gave the treatment a rating of 4.3 on a scale of 1 to 5, whereas those receiving placebo scored their treatment 3.7 (P=.0285). The hospital admission rate was not different between treatment groups (P=.1088).

    Conclusion: IV ketamine at a dose low enough to avoid dysphoric reactions demonstrated no increased bronchodilatory effect compared with standard therapy in treating exacerbations of asthma in the ED. Although there was a slight increase in satisfaction in the ketamine group, no clinical benefit in terms of hospital admission rate was noted. [Howton JC, Rose J, Duffy S, Zoltanski T, Levitt MA: Randomized, double-blind, placebo-controlled trial of intravenous ketamine in acute asthma.

    Ann Emerg Med February 1996; 27:170-175.]

    And another one for kids:

    The Efficacy of Ketamine in Pediatric Emergency Department Patients Who Present With Acute Severe Asthma
    Joseph Y. Allen, MD, FAAP, Charles G. Macias, MD, FAAP

    Received 27 April 2004; received in revised form 15 September 2004 and 21 January 2005; accepted 4 February 2005 published online 31 May 2005.

    Study objective
    We determine whether a continuous infusion of ketamine can decrease the severity of a moderately severe acute asthma exacerbation by a clinically significant 2 points using a 15-point Pulmonary Index scoring scale.

    A double-blinded, randomized, placebo-controlled trial was performed to evaluate patients aged 2 to 18 years who presented to a pediatric emergency department with an acute asthma exacerbation. Exclusion criteria included temperature greater than 39°C (102°F), focal infiltrate on radiograph, or any glucocorticoid use in the last 72 hours. Eligible patients received 3 treatments with albuterol, ipratropium bromide, and a dose of oral or parenteral glucocorticoids. If the Pulmonary Index score remained 8 to 14, enrollment proceeded. All enrolled patients received continuous nebulized albuterol at 10 mg/hour and were randomized to receive an intravenous bolus of 0.2 mg/kg of ketamine, followed by a 2-hour ketamine infusion at 0.5 mg/kg per hour or an equal-volume regimen with normal-saline placebo. A Pulmonary Index score was performed on patients at 0, 30, 60, 90, and 120 minutes.

    Sixty-eight patients were enrolled, with 33 randomized to the ketamine infusion and 35 randomized to placebo. Mean ages of patients enrolled, chronic severity of asthma, and duration of symptoms before presentation were similar between groups. At enrollment, the mean Pulmonary Index score in the placebo group was 10.3±1.1 versus 10.5±1.5 for the ketamine group (difference of means 0.2; 95% confidence interval [CI] −0.5 to 0.8). Sixty-two patients completed the entire 2-hour infusion protocol. No significant difference between groups was seen in rate of improvement in the Pulmonary Index score at completion. The mean decrease in the Pulmonary Index scores at the end of the infusion was 3.6±1.3 in the placebo group versus 3.2±2.0 in the ketamine group (difference of means 0.4; 95% CI −0.4 to 1.3). No short-term adverse effects necessitating discontinuation of the infusion or adverse behavioral impacts at 48 hours after discharge were noted.

    We conclude that ketamine given at 0.2 mg/kg followed by an infusion of 0.5 mg/kg per hour for 2 hours provided no incremental benefit to standard therapy in this cohort of children with a moderately severe asthma exacerbation.
  23. pushinepi2

    pushinepi2 Bicarb chaser 10+ Year Member

    A review of the currently available research indicates that you can save asthmatics from the brink of death with a single, succint, and directed

  24. :laugh:
  25. docB

    docB Chronically painful Moderator Emeritus Lifetime Donor 10+ Year Member

    I will tube an asthmatic if they need it. I determine "needing it" based on mental status. I use ketamine as my induction agent for young, asthmatic RSI but not as an independent med for bronchodilation. Someone mentioned using morphine. I do use morphine or ativan in small doses but that's usually for the little old lady COPDers more than the younger asthmatics. It seems like the anxiolysis and decrease of air hunger helps.

    As for Mag. I don't think it hurts but I don't hang my hat on it. I had an issue once with a medic who called with a report of "I'm going to have to tube this woman if I don't give mag." I said if she was that bad just tube her. Mag isn't a make or break drug for RAD. This medic just loved mag.

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