Near-Fatal Asthma

By Mark D. Siegel, MD, FCCP

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Objectives

1. Identify which patients are at risk for fatal and near-fatal asthma.
2. Describe the pathophysiology of near-fatal asthma.
3. Describe the mechanisms contributing to and the consequences of dynamic hyperinflation.
4. Understand the major options available for the treatment of near-fatal asthma.
5. Understand the principles of mechanical ventilation for the management of intubated asthmatic patients.

Key words

airways inflammation; asthma; barotrauma; hyperinflation; mechanical ventilation; permissive hypercapnia

Abbreviations

autoPEEP = intrinsic positive end-expiratory pressure; DHI = dynamic hyperinflation; DVT = deep venous thrombosis; FRC = functional residual capacity; I:E = inspiratory/expiratory; MDI = metered-dose inhaler; NFA = near-fatal asthma; Pel = elastic recoil pressure of the respiratory system; Ppk = peak airway pressure; Ppl = plateau pressure; Pr = pressure related to airway resistance; Raw = airway resistance; Te = expiratory time; E = minute volume; VT = tidal volume

"The best treatment of status asthmaticus is to treat it three days before it occurs."—Thomas L. Petty, MD, Master FCCP¹

Few tragedies exceed the loss of an otherwise healthy person to asthma. Although largely preventable, asthma deaths are not rare, occurring approximately 5, 000 times per year in the United States.² Life-threatening attacks requiring ICU admission, intubation, and mechanical ventilation are far more common.

In the last two decades, improved treatment for those requiring mechanical ventilation has radically improved short-term prognosis. This review will describe the epidemiology of near-fatal asthma (NFA), characterize its pathology and pathogenesis, and summarize current management principles, emphasizing a safe and effective approach to mechanical ventilation.

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