RAGEback: Weingart and co on Asthma

This RAGEback includes commentary and reaction to the RAGE Session Three discussion of severe life-threatening acute asthma. It features comments from Mary Shue on THAM, Greg Miller on lignocaine and someone called Scott Weingart (anyone heard of him?) on non-invasive ventilation.

Here’s some stuff on lignocaine (a fairly evidence free zone!):

  • BestBets: Lignocaine as a pretreatment to Rapid Sequence Induction of patients with Status Asthmaticus 
  • Maslow AD, Regan MM, Israel E, Darvish A, Mehrez M, Boughton R, Loring SH. Inhaled albuterol, but not intravenous lidocaine, protects against intubation-induced bronchoconstriction in asthma. Anesthesiology. 2000 Nov;93(5):1198-204. PubMed PMID: 11046206. [Free Full Text]
  • More recently though, this paper suggested some beneficial effects on bronchoconstriction post-intubation:
    Adamzik M, Groeben H, Farahani R, Lehmann N, Peters J. Intravenous lidocaine after tracheal intubation mitigates bronchoconstriction in patients with asthma. Anesth Analg. 2007 Jan;104(1):168-72. PubMed PMID: 17179265.

Some stuff by Scott Weingart on Emcrit.org relevant to this discussion:

Finally, some useful links from the LITFL Critical Care Compendium:

Thanks again for listening to the RAGE!

9 thoughts on “RAGEback: Weingart and co on Asthma”

  1. What is there to be gained by not intubating the patient who picks up on NIV? At this point aren’t they exhausted, and close enough to respiratory arrest that you wanted to intubate them? My understanding was that the risks in asthma were mainly those of positive pressure ventilation rather than induction etc. and those should be similar for NIV, except you lack a definitive airway in an (up to this point) unstable and potentially obtunded patient. Is the improvement *that* dramatic? What am I missing?

    1. There are a few reasons:
      1. Laryyngoscopy and tube placement are huge inducers of bronchospasm

      2. These pts recover rapidly as soon as their CO2 comes down and they chill our for a bit. Most can go to lower acuity beds, or if they rot long enough may be able to be sent home

      3. ICUs are dangerous places where bad things happen

  2. Greetings Dr. Weingart
    Great talk as usaul..
    Your comment about the problem of the severely asthmatic patients in the pre arrest stage being inspiratory rather than expiratory really caught my attention and admiration as well..

    I work at a place where I frequently see severe asthmatic patients at that point where they become exhausted, loose consciousness, bradycardic and a lot of times apnoeic.
    In my ER we surly don’t have the luxury of NIV or even mechanical ventilation.
    At that stage, when every thing else fails, what I do and it works every time, is that I lay my poor patient supine, grab my BVM, connect it with 100% O2 and start ventilating trying my best to synchronize my bag pressures with the patient’s own inspiration.
    Mean while, I give IV aminophilline (infusion over 30 – 60 minutes), rarely IM epinephrine 1:1000..
    Few minutes of that and the patient recovers and starts breathing on his own, then I re-continue the rest of the managment..

    I don’t have statistics but that works successfully with every case that reaches that stage..

    I would like please to know your opinion and experience rgarding the use of Aminophylline..

    Very much appreciated..

    Osama Muhammad Ali
    EM registrar – Sudan

    1. Hi Osama
      My experience with aminophylline is primarily from working in PICU.
      While I’ve always been impressed by it’s emetogenic effects, I remain uncertain of its clinical effectiveness. This is partly because it’s use is typically part of a cocktail of agents making it difficult to know which, if any, are having the desired effect.

  3. We’ve had a great result with turning a delayed sequence intubation into no intubation at all with a severe asthma case in Bendigo. I can’t claim it myself as it was a colleague but it went just like Scott describes. Everything set up for a tube, patient about to give up, NIV on, tiny doses of ketamine (10-20mg at a time until tolerating mask) and then watch and wait. They guy just eased down his breathing, his chest shrunk back down to a normal sort of size, oxygenation improved,, ketamine allowed to wear off, NIV came off and nebulised mask went back on.

    It’s only an anecdote but one case in your own ED makes the stuff you hear about from podcast/journal/blog seem believable. I’m convinced.

    It’s just a shame that community care of asthma is getting so damn good. We just don’t see the severe end-stage asthma that we used to!

  4. Great stuff and thanks for posting. One thing not discussed which seems to be on the horizon is extracorporeal CO2 removal of patients with severe COPD, and potentially asthma. The columbia ECMO program has advocated for allowing mobilization of patients with V-V ECCO2 removal rather than intubation, sedation and weakness/deconditioning to ensue ultimately resulting in discharge to a SNF. Essentially patients failing NIV get low flow ECMO (their pilot study of 5 patients were intubated and rapidly extubated, but apparently their soon to go to press study compared ECCO2 vs. intubation after failing NIV).

    Abrams DC et al. Pilot study of extracorporeal carbon dioxide removal to facilitate extubation and ambulation in exacerbations of chronic obstructive pulmonary disease. Annals of the American Thoracic Society. 2013 Aug;10(4):307-14.

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