Alexandre T Rotta MD FCCM Professor of Pediatrics The Linsalata Endowed Chair in Pediatric Critical Care and Emergency Medicine Chief Pediatric Critical Care and Emergency Medicine ID: 1033734
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1. Update on Critical and Near-Fatal AsthmaAlexandre T. Rotta, MD, FCCMProfessor of PediatricsThe Linsalata Endowed Chair in Pediatric Critical Care and Emergency Medicine Chief, Pediatric Critical Care and Emergency Medicine
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3. NomenclatureStatus Asthmaticus…Acute Asthma Exacerbation: Acute manifestation of airway obstruction in a patient known to have asthmaAcute Severe Asthma: an asthma attack unresponsive to repeated doses of beta-agonists and requiring hospital admission Critical Asthma: Acute Severe Asthma that requires an ICU admissionNear-Fatal Asthma: Critical Asthma that requires intubation and mechanical ventilation
4. Epidemiology (USA)Most common chronic illness among children (9.5%)150,000 hospital admissions/yearHospitalizations are decreasingCritical asthma admissions are increasingOhio Collaborative: 25% of asthma admissions = PICU5-12% need mechanical ventilation3-5% need NIVMortality is lowAcute Severe Asthma: <0.1%Critical Asthma: 0.3%Near-Fatal Asthma: 4%
5. Rotta AT et al, Asthma, in Fuhrman and Zimmerman’s Pediatric Critical Care, 2011
6. Rotta AT et al, Asthma, in Pediatric Critical Care, 2011
7. Rotta AT et al, Asthma, in Fuhrman and Zimmerman’s Pediatric Critical Care, 2011
8. Rotta AT et al, Asthma, in Fuhrman and Zimmerman’s Pediatric Critical Care, 2011
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10. SteroidsUsage (%)
11. Inhaled AlbuterolUsage (%)
12. Inhaled Lev-AlbuterolUsage (%)
13. IV TerbutalineUsage (%)
14. Inhaled Ipratropium BromideUsage (%)
15. IV Magnesium SulfateUsage (%)
16. IV MethylxanthinesUsage (%)
17. AntibioticsUsage (%)
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19. AlbuterolUsage (%)ContinuousIntermittent
20. Terbutaline IVUsage (%)
21. CorticosteroidsUsage (%)
22. Ipratropium BromideUsage (%)
23. Aminophylline/TheophyllineUsage (%)
24. Magnesium SulfateUsage (%)
25. KetamineUsage (%)
26. Neuromuscular BlockadeUsage (%)
27. Critical Asthma TreatmentOxygenIV FluidsGlucocorticoidsInhaled b-agonistIpratropium bromideMagnesium sulfateIntravenous b-agonistMethylxanthinesKetamineMechanical ventilationAnalgesia/sedationNeuromuscular blockadeInhaled anestheticsAntibioticsBronchoscopyECLS
28. Critical Asthma TreatmentOxygenIV FluidsGlucocorticoidsInhaled b-agonistIpratropium bromideMagnesium sulfateIntravenous b-agonistMethylxanthinesKetamineMechanical ventilationAnalgesia/sedationNeuromuscular blockadeInhaled anestheticsAntibioticsBronchoscopyECLS
29. Critical Asthma TreatmentOxygenIV FluidsGlucocorticoidsInhaled b-agonistIpratropium bromideMagnesium sulfateIntravenous b-agonistMethylxanthinesKetamineMechanical ventilationAnalgesia/sedationNeuromuscular blockadeInhaled anestheticsAntibioticsBronchoscopyECLS
30. Oxygen
31. Oxygenb-agonists abolish regional pulmonary hypoxic vasoconstriction (Connett 1993, Tal 1984)Oxygen should be the driver gas for nebulizations and used for SpO2 <92%No risk of oxygen-induced respiratory depression
32. Critical Asthma TreatmentOxygenIV FluidsGlucocorticoidsInhaled b-agonistIpratropium bromideMagnesium sulfateIntravenous b-agonistMethylxanthinesKetamineMechanical ventilationAnalgesia/sedationNeuromuscular blockadeInhaled anestheticsAntibioticsBronchoscopyECLS
33. PreloadEdema
34. Critical Asthma TreatmentOxygenIV FluidsGlucocorticoidsInhaled b-agonistIpratropium bromideMagnesium sulfateIntravenous b-agonistMethylxanthinesKetamineMechanical ventilationAnalgesia/sedationNeuromuscular blockadeInhaled anestheticsAntibioticsBronchoscopyECLS
35. GlucocorticoidsAsthma is a disease of inflammationPlay a central role in treatmentIncrease density, affinity and efficiency of b-receptorsRouteInhaled steroids: Not indicatedEnteral (prednisolone)IM DexamethasoneIV (methylprednisolone); 2 mg/kg bolus followed by 0.5 to 1 mg/kg/dose q 6hrs
36. Critical Asthma TreatmentOxygenIV FluidsGlucocorticoidsInhaled b-agonistIpratropium bromideMagnesium sulfateIntravenous b-agonistMethylxanthinesKetamineMechanical ventilationAnalgesia/sedationNeuromuscular blockadeInhaled anestheticsAntibioticsBronchoscopyECLS
37. Inhaled b-agonistAlbuterolContinuousIntermittentLevalbuterolIsoproterenolisoproterenol > fenoterol > albuterol > terbutaline > isoetharine > metaproterenol
38. Camargo Jr CA, Spooner C, Rowe BH. Continuous versus intermittent beta-agonists for acute asthma. Cochrane Database of Systematic Reviews 2003
39. Papo MC et al, Crit Care Med 1993
40. Qureshi et al, Ann Emer Med 2005
41. Critical Asthma TreatmentOxygenIV FluidsGlucocorticoidsInhaled b-agonistIpratropium bromideMagnesium sulfateIntravenous b-agonistMethylxanthinesKetamineMechanical ventilationAnalgesia/sedationNeuromuscular blockadeInhaled anestheticsAntibioticsBronchoscopyECLS
42. N Engl J Med 1998;339:1030-5
43. Critical Asthma TreatmentOxygenIV FluidsGlucocorticoidsInhaled b-agonistIpratropium bromideMagnesium sulfateIntravenous b-agonistMethylxanthinesKetamineMechanical ventilationAnalgesia/sedationNeuromuscular blockadeInhaled anestheticsAntibioticsBronchoscopyECLS
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45. Critical Asthma TreatmentOxygenIV FluidsGlucocorticoidsInhaled b-agonistIpratropium bromideMagnesium sulfateIntravenous b-agonistMethylxanthinesKetamineMechanical ventilationAnalgesia/sedationNeuromuscular blockadeInhaled anestheticsAntibioticsBronchoscopyECLS
46. Intravenous TerbutalineDose range: 0.1 to 10 mcg/kg/minUsual dose: 1 to 4 mcg/kg/minMonitor closelyHypokalemiaArrhythmiasChest pain
47. Critical Asthma TreatmentOxygenIV FluidsGlucocorticoidsInhaled b-agonistIpratropium bromideMagnesium sulfateIntravenous b-agonistMethylxanthinesKetamineMechanical ventilationAnalgesia/sedationNeuromuscular blockadeInhaled anestheticsAntibioticsBronchoscopyECLS
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49. Critical Asthma TreatmentOxygenIV FluidsGlucocorticoidsInhaled b-agonistIpratropium bromideMagnesium sulfateIntravenous b-agonistMethylxanthinesKetamineMechanical ventilationAnalgesia/sedationNeuromuscular blockadeInhaled anestheticsAntibioticsBronchoscopyECLS
50. KetamineDissociative anestheticBronchodilationSialorrheaEmergence phenomenon, hallucinationsBolus 1-2 mg/kg, IVInfusion 1-2 mg/kg/h, IVBe ready to intubate
51. IntubationFentanyl or KetamineMidazolamNMB: Vecuronium or cisatracuriumCuffed ET TubeSlow hand bagging once intubated, long expiratory timesObtain chest Xray
52. Ventilation Strategies in Asthma43%23%0%Mortality (%)Scoggins CH, et alJAMA 1977Picardo C, et alEur J Respir Dis 1983Darioli R, Perret C Am Rev Respir Dis 1984Traditional Strategy Hypercapnia
53. Ventilator ModesPC-SIMVDecelerating insp flowSquare pressure waveformVC-SMIVConstant inspiratory flowTriangular pressure waveformAllows for measurement of peak-to-plateau pressurePRVCBest of both strategies
54. Ventilator SettingsPRVC-SIMV modeTidal volumes: 8 to 12 ml/kgRate 6 to 12 breaths/minInspiratory time: 1 to 1.5 secExpiratory time: 4 to 9 secPEEPZero PEEP for paralyzed patientsLow level PEEP (less than 8) set below auto-peep for unparalized patients to facilitate synchrony
55. Modified from Tuxen Am Rev Respir Dis 1989
56. Shein SL, Rotta AT. RBTI 2016
57. Rotta AT et al, Asthma, in Pediatric Critical Care, 2011
58. Extracorporeal Life SupportELSO RegistryAsthma Primary Diagnosis256 runs / 32,975 runs0.78% of all pediatric and adult runsSurvival 83%
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60. Alex.Rotta@UHhospitals.org