The management of life-threatening airflow obstruction

T. Corbridge, J. B. Hall*

*Corresponding author for this work

Research output: Contribution to journalReview article

1 Scopus citations

Abstract

Patients with status asthmaticus commonly develop progressive airflow obstruction over hours to days as a result of airway wall inflammation, bronchospasm and intraluminal mucus. In sudden asphyxic asthma, airflow obstruction results primarily from smooth muscle mediated bronchospasm. Airflow obstruction causes ventilation-perfusion inequality, lung hyperinflation, and increased work of breathing. Severe cases are characterized by an inability to speak, diaphoresis, altered mental status, poor air movement, widened pulsus paradoxus, accessory muscle use, and low peak expiratory flow rate. Lack of early response to bronchodilator therapy, a rising partial pressure of carbon dioxide, and need for assisted ventilation are additional markers of severe disease. First line treatment consists of oxygen, beta agonists, and corticosteroids. In mechanically ventilated patients, bronchodilators must be given in higher dosages to achieve a physiologic effect. Agents of debated efficacy include theophylline, anticholinergics, and magnesium sulfate. Heliox and noninvasive positive pressure ventilation are promising adjuncts to the treatment of nonintubated patients. In patients requiring intubation and mechanical ventilation, a ventilatory strategy should be used that avoids excessive lung hyperinflation by prolonging expiratory time. In many cases, this strategy requires acceptance of hypercapnea and high peak airway pressures. Patients should be aggressively sedated to decrease the need for muscle paralysis and the risk of post paralytic myopathy. Indirect evidence suggests that the current approach to mechanical ventilation in acute severe asthma decreases morbidity and mortality; however, the key to the management of this disease (which in many cases represents a failure of outpatient management) is patient education and disease prevention.

Original languageEnglish (US)
Pages (from-to)294-306
Number of pages13
JournalIntensivmedizin und Notfallmedizin
Volume34
Issue number4
DOIs
StatePublished - May 1 1997

Keywords

  • anti-inflammatory therapy
  • bronchodilator therapy
  • lung hyperinflation
  • permissive hypercapnia
  • post paralytic myopathy
  • status asthmaticus

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Medicine(all)

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