Historical features (sputum production, fever).If lucky may see traditional signs (e.g., subcutaneous crepitus).Thoracic ultrasound shows lack of lung slide on affected side.Wheezing audible from across the room (this is not a feature of severe asthma!).Vocal cord dysfunction (or other upper airway obstruction):.Involvement of other organ systems (e.g.Add glycopyrrolate to avoid bronchorrhea & dilate bronchi (e.g., 0.2 mg IV q6hr).ĭiagnoses that are often confused with asthma (& clues to help suggest them).Ketamine dose: Load with 1-2 mg/kg then infuse at 1-2 mg/kg/hr.If refractory: dissociative ketamine gtt 📖 Initiate early to reduce the risk of propofol infusion syndrome.Permissive hypercapnia: target pH >~7.15 if able.

Key is a low respiratory rate (~12-14 breaths/min).Acetaminophen scheduled (usually 1 gram PO q6hr).Fentanyl boluses PRN (& infusion if needed for vent synchrony).

High-dose propofol infusion is very helpful (~60-80 ug/kg/min).

It is often helpful to push the bicarb up to a high-normal level (29 mM) or moderately elevated level (35 mM).

Bicarbonate if there is difficulty achieving an adequate pH.

Steroid: Methylprednisolone ~2 mg/kg/day may be reasonable.

Bronchodilators: Frequent albuterol nebs (2.5 mg q20 min) or continuous neb (10-15 mg/hr).

Intubated asthmatic basic medication package:

Glycopyrrolate (0.2 mg IV less evidence).

Terbutaline (0.25 mg SC, q15-30 min x3 doses PRN).

Start 5 mcg/min, titrate 1-10 mcg/min (peripheral IV is fine).

Bradycardia related to dexmedetomidine.

Unable to tolerate inhaled bronchodilators (re: coughing).

(If wholly unable to tolerate BiPAP, may use high-flow nasal cannula or heliox 📖).

May use small doses of opioid while waiting for dexmedetomidine to take effect, if severely dyspneic (e.g., fentanyl 25 mcg IV PRN).

This may be helpful as an anxiolytic agent, even if the patient is able to tolerate the BiPAP mask.

Start dexmedetomidine infusion at maximal rate (down-titrate as takes effect).

Methylprednisolone 125 mg IV x1 (or equivalent steroid).

Ipratropium (may use 1.5 mg over first hour, then 0.5 mg nebulized q4-6 hr).

Stacked albuterol nebs (2.5-5 mg q20) or continuous neb (10-15 mg/hr).

Non-intubated asthmatic basic medication package:

“We're bagging because the vent keeps alarming”.

General principles of ventilating an asthmatic.

Beware of asthma treatment pseudofailure.

Dead space vs shunt anesthesia