Management of Status Asthmaticus

  • Jacob Scott
  • Ryan HadleyEmail author


Care of patients with life-threatening asthma in the intensive care unit (ICU) is challenging. Due to alterations in airway physiology, standard ventilation strategies cannot be employed. Management of patients with status asthmaticus, especially when requiring invasive mechanical ventilation, is requisite knowledge for the intensivist. In this chapter we outline the standard care that should be provided to patients with life-threatening asthma in the ICU, which includes a critique of available evidence and a review of pertinent physiologic changes. Additionally, we review salvage therapies, and their evidence or lack thereof, for patients failing typical treatment.


Life-threatening asthma Status asthmaticus Mechanical ventilation Invasive mechanical ventilation (IMV) Critical care Intensive care unit (ICU) Asthma 

Supplementary material

Video 23.1

Lung point (From Doerschug et al. [18]. The Annals of the American Thoracic Society is an official journal of the American Thoracic Society. Republished with permission of the American Thoracic Society. Copyright © 2015 American Thoracic Society) (MP4 4901 kb)


  1. 1.
    Truwit JD, Marini JJ. Evaluation of thoracic mechanics in the ventilated patient part II: applied mechanics. J Crit Care. 1988;3(3):199–213.CrossRefGoogle Scholar
  2. 2.
    Williams TJ, et al. Risk factors for morbidity in mechanically ventilated patients with acute severe asthma. Am Rev Respir Dis. 1992;146(3):607–15.CrossRefPubMedGoogle Scholar
  3. 3.
    Rodrigo GJ, Rodrigo C. Continuous vs intermittent beta-agonists in the treatment of acute adult asthma: a systematic review with meta-analysis. Chest. 2002;122(1):160–5.CrossRefPubMedGoogle Scholar
  4. 4.
    Besbes-Ouanes L, et al. Continuous versus intermittent nebulization of salbutamol in acute severe asthma: a randomized, controlled trial. Ann Emerg Med. 2000;36(3):198–203.CrossRefPubMedGoogle Scholar
  5. 5.
    Stoodley RG, Aaron SD, Dales RE. The role of ipratropium bromide in the emergency management of acute asthma exacerbation: a metaanalysis of randomized clinical trials. Ann Emerg Med. 1999;34(1):8–18.CrossRefPubMedGoogle Scholar
  6. 6.
    Rodrigo GJ, Rodrigo C. The role of anticholinergics in acute asthma treatment: an evidence-based evaluation. Chest. 2002;121(6):1977–87.CrossRefPubMedGoogle Scholar
  7. 7.
    National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007;120(5 Suppl):S94–138.Google Scholar
  8. 8.
    Kuyper LM, et al. Characterization of airway plugging in fatal asthma. Am J Med. 2003;115(1):6–11.CrossRefPubMedGoogle Scholar
  9. 9.
    Rowe BH, Keller JL, Oxman AD. Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med. 1992;10(4):301–10.CrossRefPubMedGoogle Scholar
  10. 10.
    Emerman CL, Cydulka RK. A randomized comparison of 100-mg vs 500-mg dose of methylprednisolone in the treatment of acute asthma. Chest. 1995;107(6):1559–63.CrossRefPubMedGoogle Scholar
  11. 11.
    Leatherman J. Mechanical ventilation for severe asthma. Chest. 2015;147(6):1671–80.CrossRefPubMedGoogle Scholar
  12. 12.
    Corne S, et al. Effect of inspiratory flow rate on respiratory rate in intubated ventilated patients. Am J Respir Crit Care Med. 1997;156(1):304–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Leatherman JW, McArthur C, Shapiro RS. Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Crit Care Med. 2004;32(7):1542–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301–8.Google Scholar
  15. 15.
    Tuxen DV, Lane S. The effects of ventilatory pattern on hyperinflation, airway pressures, and circulation in mechanical ventilation of patients with severe air-flow obstruction. Am Rev Respir Dis. 1987;136(4):872–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Brenner B, Corbridge T, Kazzi A. Intubation and mechanical ventilation of the asthmatic patient in respiratory failure. Proc Am Thorac Soc. 2009;6(4):371–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Lichtenstein DA, et al. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005;33(6):1231–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Doerschug KC, Schmidt GA. Intensive care ultrasound: III. Lung and pleural ultrasound for the intensivist. Ann Am Thorac Soc. 2013;10(6):708–12.CrossRefPubMedGoogle Scholar
  19. 19.
    Kew KM, Kirtchuk L, Michell CI. Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department. Cochrane Database Syst Rev. 2014;5, CD010909.Google Scholar
  20. 20.
    Alter HJ, Koepsell TD, Hilty WM. Intravenous magnesium as an adjuvant in acute bronchospasm: a meta-analysis. Ann Emerg Med. 2000;36(3):191–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Goodacre S, et al. The 3 Mg trial: a randomised controlled trial of intravenous or nebulised magnesium sulphate versus placebo in adults with acute severe asthma. Health Technol Assess. 2014;18(22):1–168.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Travers AH, et al. Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute asthma. Cochrane Database Syst Rev. 2012;12, CD010179.PubMedGoogle Scholar
  23. 23.
    Lewis L, et al. Albuterol administration is commonly associated with increases in serum lactate in patients with asthma treated for acute exacerbation of asthma. Chest. 2014;145(1):53–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Rodrigo GJ, Rodrigo C. Elevated plasma lactate level associated with high dose inhaled albuterol therapy in acute severe asthma. Emerg Med J. 2005;22(6):404–8.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Hashemian SM, Fallahian F. The use of heliox in critical care. Int J Crit Illn Inj Sci. 2014;4(2):138–42.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Rodrigo GJ, et al. Use of helium-oxygen mixtures in the treatment of acute asthma: a systematic review. Chest. 2003;123(3):891–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Rodrigo G, et al. Heliox for nonintubated acute asthma patients. Cochrane Database Syst Rev. 2006;4, CD002884.Google Scholar
  28. 28.
    Schaeffer EM, et al. Oxygenation in status asthmaticus improves during ventilation with helium-oxygen. Crit Care Med. 1999;27(12):2666–70.CrossRefPubMedGoogle Scholar
  29. 29.
    Lim WJ, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev. 2012;12, CD004360.PubMedGoogle Scholar
  30. 30.
    Rosseel P, Lauwers LF, Baute L. Halothane treatment in life-threatening asthma. Intensive Care Med. 1985;11(5):241–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Bierman MI, et al. Prolonged isoflurane anesthesia in status asthmaticus. Crit Care Med. 1986;14(9):832–3.CrossRefPubMedGoogle Scholar
  32. 32.
    Hemming A, MacKenzie I, Finfer S. Response to ketamine in status asthmaticus resistant to maximal medical treatment. Thorax. 1994;49(1):90–1.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Hemmingsen C, Nielsen PK, Odorico J. Ketamine in the treatment of bronchospasm during mechanical ventilation. Am J Emerg Med. 1994;12(4):417–20.CrossRefPubMedGoogle Scholar
  34. 34.
    Strube PJ, Hallam PL. Ketamine by continuous infusion in status asthmaticus. Anaesthesia. 1986;41(10):1017–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Khan MF, et al. Bronchoscopy as a rescue therapy in patients with status asthmaticus: two case reports and review of literature. Saudi J Anaesth. 2013;7(3):327–30.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    DiFrancia M, Barbier D, Orehek J. Left lung asthma. Chest. 1993;104(6):1919–20.CrossRefPubMedGoogle Scholar
  37. 37.
    Mikkelsen ME, et al. Outcomes using extracorporeal life support for adult respiratory failure due to status asthmaticus. ASAIO J. 2009;55(1):47–52.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Mikkelsen ME, et al. Emergency extracorporeal life support for asphyxic status asthmaticus. Respir Care. 2007;52(11):1525–9.PubMedGoogle Scholar
  39. 39.
    Bein T, et al. A new pumpless extracorporeal interventional lung assist in critical hypoxemia/hypercapnia. Crit Care Med. 2006;34(5):1372–7.CrossRefPubMedGoogle Scholar
  40. 40.
    Jung C, et al. Pumpless extracorporeal lung assist for the treatment of severe, refractory status asthmaticus. J Asthma. 2011;48(1):111–3.CrossRefPubMedGoogle Scholar
  41. 41.
    Elliot SC, et al. Pumpless extracorporeal carbon dioxide removal for life-threatening asthma. Crit Care Med. 2007;35(3):945–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Pulmonary and Critical Care MedicineSpectrum HealthGrand RapidsUSA

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