Status Asthmaticus

The crashing asthmatic patient is perhaps one of the most frightening of patients to treat - Peter Kas

Status Asthmaticus
Status Asthmaticus

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The Crashing Asthmatic Patient

I have 2 rules here:

  1. Do not intubate, if at all possible. It will be horrific... They can go on for a while, so there is a little bit of time, but only a little bit- so prime your team and go go go! Do not intubate if at all possible.
  2. Throw everything you have at the patient. This is the time to go in all guns blazing.

We use my old friend the nasal canula. We put them on under the mask delivering the salbutamol. I turn them up to somewhere above 15L/min, but probably closer to 60L/min. They don’t bother the patient at this point as she is CO2 narcotised. We then run the mask over this at 6L/min and deliver the salbutamol.

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 The Crashing Asthmatic Patient

The Crashing Asthmatic Patient is perhaps one of the most frightening of patients to treat. I’m not talking about the patient that has wheeze and gets five or six nebs and gets better in an hour. I’m talking about the sweaty, drowsy, tiring, non-responsive patient that you know has a good chance of dying.


Intubation occurs in a small number of asthmatic patients admitted to the PICU (4-10% with significant variability). No clear indications and largely based on clinical judgment.

Life in the Fastlane

induction agent: — ketamine preferred due to bronchodilation — propofol is an alternative, but beware hypotension.

the NNT

In summary, for adults presenting to the ED with moderate to severe asthma exacerbations, intravenous magnesium sulfate therapy used as an adjunct to routine treatment (oxygen, short acting beta agonists and systemic corticosteroids) or when these treatments fail, reduces the need for hospitalization and likely has minimal adverse events. Therefore, we have assigned a color recommendation of Green (benefits > harm) to this treatment.

International Emergency Medicine Education Project

Inhaled short-acting beta2-agonists (SABAs): Use 4-10 puffs pMDI with a spacer in mild or moderate attacks. For severe attacks, administer 1 nebule every 20 minutes for 1 hour.

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