Status asthmaticus: Strategies for stabilization after intubation

For patients with status asthmaticus that is refractory to drugs, mechanical ventilation helps prevent cardiac and cerebral complications. The decision to intubate often is based on the clinician's assessment of impending cardiopulmonary arrest. We recommend rapid-sequence induction using a large-diameter oral endotracheal tube. To minimize dynamic hyperinflation of the lung during ventilation, start with the following ventilator settings: respiratory rate, 12 to 14 breaths per minute; tidal volume, 7 to 8 mL/kg; inspiratory flow rate, 80 L/min; and no positive end-expiratory pressure. Maintain single-breath plateau pressure at less than 30 cm H₂O by adjusting minute ventilation as appropriate. Sedation and analgesia are indicated for all patients during ventilation; propofol (or a benzodiazepine) combined with an opioid is a good choice. Consider short-term paralysis when sedation is insufficient.