Asthma is a common affliction, affecting 8-10 percent of the population. Many childhood asthmatics grow out of the disorder in adulthood, so a disproportionate percentage of people with asthma are children. For most people, asthma is a minor inconvenience, akin to—and often associated with—seasonal allergies. An unlucky fraction of asthmatics, however, have a more severe form of the illness. About 11,000 people die of asthma each year, and the rate of asthma deaths has increased 50 percent since 1980. Most asthma deaths are preventable with prompt, competent emergency care. Here’s what you need to know about intubation and ventilation of asthma patients.
Intubation: Risks and Indications
Intubation can exacerbate bronchospasms, making breathing even more difficult and triggering laryngospasms. Historically, intubation has been linked with a 13-16 percent risk of mortality. This may be due to the dangers of intubation itself, but may also be because asthmatics who require intubation are already at a high risk of dying. First responders should try less invasive measures first, particularly if the patient is breathing on their own and not crashing.
Some indications for intubation include:
- Respiratory or cardiac arrest
- Failure of less invasive methods to reduce hypoxia and support respiration
- Severe hypoxia
- Rapidly declining mental status
- Loss of consciousness
Acute Management of Asthma Attacks
The first line of defense against an asthma attack is a rescue inhaler. If a person with asthma does not improve with the use of a rescue inhaler, medication can often reverse an asthma attack. The most effective drugs include:
- Beta agonists
- Anticholinergics
- Glucocorticoids
- Magnesium sulfate
- Leukotriene inhibitors
Following a severe asthma attack, a patient may need to continue using inhaled anticholinergics for 24-36 hours.
When and How to Manage the Airway
Asthmatics may need several medication doses, and often several medicines, to see improvement. For patients with airway inflammation, a corticosteroid is the first line of treatment. When airflow is weak, choose a beta agonist and/or anticholinergic, as well as intravenous magnesium.
Carefully monitor the patient’s vital signs. If FEV1 or PEF is greater than or equal to 70 percent of personal best effort for 60 minutes or longer, the patient may be discharged. Oxygen saturation must remain about 90 percent. If it does not, the patient requires hospitalization. Noninvasive ventilation or intubation may be appropriate if a patient is crashing or if a hospitalized patient cannot sustain oxygen saturation levels above 90 percent with supportive care.
When medication fails, mask ventilation is the preferred treatment. Avoid high per-minute ventilation rates in asthmatics, because this may decrease venous return and weaken cardiopulmonary function.
Intubation is generally only appropriate in an emergency department, but if a patient is crashing, it may be the only option. Carefully evaluate risks and benefits, and only intubate after medication has failed and the patient shows signs of severe hypoxia. As with any other patient who must be intubated, explain the procedure to the patient and ensure their head and body are supported. Only intubate a patient when you can visualize their airway. Inflammation can compromise an airway and make intubation difficult or even impossible.
A crashing asthma patient can quickly decline. Transporting the patient may not be possible, especially when first responders encounter asthmatics at schools, playgrounds, and in other locations without ready access to wall-mounted suction. Stocking your kit with emergency airway management tools, as well as drugs to reverse asthma attacks, can save lives. The right portable emergency suction unit is a critical part of your trauma kit because it allows you to quickly tend to a patient without moving them. For help choosing the right device for your needs, download our free guide, The Ultimate Guide to Purchasing a Portable Emergency Suction Device.
Editor's Note: This blog was originally published in June 2019. It has been re-published with additional up to date content.
