Intubation and Ventilation of the Asthmatic Patient: What You Need to Know

Asthma is a common affliction, affecting 8% to 10% e 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 4,000 people die of asthma each year, and it is a contributing factor to another 7,000 deaths. 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% to 16% mortality risk.

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 independently 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 to 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 and intravenous magnesium.

• Carefully monitor the patient’s vital signs. If FEV1 or PEF is greater than or equal to 70% 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 it may be the only option if a patient is crashing. 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 other locations without ready access to wall-mounted suction.

Stocking your kit with emergency airway management tools and drugs to reverse asthma attacks can save lives. The right portable emergency suction unit is critical to your trauma kit because you can quickly tend to a patient without moving them. To help you choose 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 May 2021. It has been re-published with additional up to date content.