Title: Mechanical ventilation of the severe asthmatic<br/>Author: Duyen Tran<br/><a href='http://umem.org/profiles/faculty/2517/'>[Click to email author]</a><hr/><p style="margin:0in;font-family:Calibri;font-size:11.0pt">   <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:12px;"><u>Intubation considerations</u></span></span></p>  <ul>   <li style="margin: 0in; font-family: Calibri; font-size: 11pt;">    <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:12px;">Use large ET tube (at least 8.0 if possible): minimizes airway resistance, facilitates aggressive pulmonary toilet and bronchoscopy if needed</span></span></li>   <li style="margin: 0in; font-family: Calibri; font-size: 11pt;">    <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:12px;">Consider using ketamine as induction agent as it has bronchodilator properties and can maintain blood pressure</span></span></li>   <li style="margin: 0in; font-family: Calibri; font-size: 11pt;">    <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:12px;">Appropriate choices for initial sedation includes propofol, fentanyl, and ketamine</span></span></li>  </ul>  <p style="margin:0in;font-family:Calibri;font-size:11.0pt">   <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:12px;"><u>Vent management strategies</u></span></span></p>  <ul>   <li style="margin: 0in; font-family: Calibri; font-size: 11pt;">    <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:12px;">No overall outcome differences between volume vs pressure control modes. Volume control has been recommended as initial mode due to familiarity and ensures your set tidal volume will be delivered.</span></span></li>   <li style="margin: 0in; font-family: Calibri; font-size: 11pt;">    <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:12px;">Goal is to minimize autoPEEP, which occurs from incomplete exhalation prior to initiation of next inhaled breath. This can be achieved by adjusting a few vent settings: decreasing RR, decreasing I:E ratio, decreasing inspiratory time, or increasing inspiratory flow rate. Allow<span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:12px;"> for permissive hypercapnia, pH >7.2 has been advocated though precise target is unknown.</span></span></span></span></li>   <li style="margin: 0in; font-family: Calibri; font-size: 11pt;">    <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:12px;">If patient becomes hemodynamically unstable, consider first disconnecting the ventilator from the ET tube and manually decompress the chest to facilitate exhalation.</span></span></li>   <li style="margin: 0in; font-family: Calibri; font-size: 11pt;">    <span style="font-family: arial, helvetica, sans-serif;"><span style="font-size: 12px;">Peak inspiratory pressures are expected to be high in the acute severe asthmatic. More important is to keep plateau pressures <30 cm H₂O to prevent lung injury.</span></span></li>   <li style="margin: 0in; font-family: Calibri; font-size: 11pt;">    <span style="font-family:arial,helvetica,sans-serif;"><span style="font-size:12px;">Don't forget to continue asthma-directed therapy. Administer albuterol via in-line nebulization unit of the vent.</span></span></li>  </ul>  <fieldset><legend>References</legend>

                <p>   <span style="font-family: arial; font-size: 14px;">Laher AE, Buchanan SK. Mechanically Ventilating the Severe Asthmatic. </span><i style="color: rgb(51, 51, 51); font-family: arial; font-size: 14px;">Journal of Intensive Care Medicine</i><span style="font-family: arial; font-size: 14px;">. 2018;33(9):491-501.</span></p>  </fieldset>