In this video I discuss a case of status asthmaticus, its management, and some learning points to ponder upon. Join this channel to get access to perks: / @salimrezaie
a definitely a challenging case but i feel extra resources definitely contribute a lot here. For resource-limited centre, this is not really an a option especially to sit monitoring the patient. thank you for an amazing case.
I usually give Bicar IVP if pH =1 before RSI, and very important after RSI forced exhalation before connection to circuit to release any iPEEP before initiating MV. After ETT if pPlat is >30, we can decrease TV to 4 ml/kg/IBW for permissive hypercapnia or another option is to change MV mode to PC
I’ve seen patients tolerate better with a minimum deltaP 8/4 or 9/5 on bipap with high RR and adjusting inspiratory time to assure 1:2- 1:3.6 to prevent more air trapping since Bronchospasm patients will feel overwhelmed with to much inspiratory pressure Delta P. I seen it allow them to take smaller volumes similar with 4ml/kg IBW without getting to high on the PIP to prevent ARDS
If you did have to intubate, that initial period right after giving the roc and having them completely calm/sedated really does provide an excellent opportunity to really interrogate their lungs on the vent and see what’s going on without all the distress/anxiety potentially clouding the clinical presentation. Also, the bigger the tube the better, can bronch them if needed and keep the air flowing without a problem
@@j.d.2369 Never really had to do that in a non-intubated patient...when they are intubated and auto-peep is occurring then yes disconnecting from the vent and pushing on the chest can be helpful.
I would also have considered intravenous theophylline loading dose plus infusion. I had 2 different cases similar to that situation, and eventually both turned out magically after theophylline as last therapeutic line. I was surprised. One of the two cases was already intubated ventilation was almost impossible. bagging against a wall. The effect of theophylline in that case was almost magical; like that of naloxone on opiates, and of course al ventilation monitoring was displayed. After all the pressure on the beta receptors, perhaps the problem was signal transduction at the intracellular level, solved by phosphodiesterase inhibition. Tidal volume immediately rising, resistance dropping. I didn't expect that effect so quick after all the other meds
Agree theophylline is certainly an option…the hard thing with these cases is we give them so many things it’s hard to say which one ultimately turned them around…most likely all of them due to multiple mechanisms of action…appreciate the comments :)
@@SalimRezaie true, I was saying this because in both cases that was my last option after a long attempts using all other meds. And immediately after the infusion I saw the curves changing quickly .
Could be the patient had poor perfusion and other meds just took a long time to kick in…no way without RCT to say one agent superior to any other…have to be careful with anecdotes
very cool take on this! i think intubation give us a false sense of security, as if once the tube is in the trachea, all's good and let the RT manage - and not staying in the room will kill the pt, imo. regarding terbutaline, what's the reasoning of using it alongside epi? it's more b2, but kinda similar - i take it's the kitchen sink approach?
Appreciate it…and yes terbutaline was more of a kitchen sink approach…not sure it adds anything to epi but I figure anything that will keep me from intubating patient…why not…no strong evidence that both are additive but then again…why not?
@@SalimRezaie on this topic, i work EMS and recently they took away our nebulizer b2, we have only the inhaler now. My "feel" is that those really bad cases, specially those pts that are somewhat agitaded, with shallow fast resps, respond better to nebs over inhalers, but i couldn't find any guidelines on that, just a lot of "maybes", "coulds", you know? trying to convince my higherups to put the nebs back. would you know any paper/guideline that supports this? or am i just getting old and biased?
Was there any consideration for IV epinephrine at a low infusion rate for beta-agonist effects? Granted, there is already a whole bunch of other systemic drugs onboard, so it likely would've been overkill. I don't have any experience with terbutaline or access to it, so I'm just trying to think through what I'd be able to provide with what I would have access to. Also, I wish I could convince my department to buy and train the department on vents so we could have access to BiPAP, but vents on 911 ambulances are unheard of around here, so I'm not holding my breath on that (no pun intended)
We thought about IV epi…however as you stated we had so many other things on board we felt it was overkill…As for BiPAP…it works very well in COPD and Asthma exacerbations…has held off intubation on more than several occasions
@SalimRezaie thanks for replying! Hopefully, someday, we'll have vents, I work a hospital side-gig where I've seen what a difference BiPAP can make compared to the O2-powered CPAP these patients come in on. I'd also rather keep these patients off an ETT, and if they're gonna buy themselves a tube anyway, i think we'd all agree we'd rather it happen where there's more than 2 sets of hands in a space the size of a shoebox 😅
The answer is it depends…a 1st, 2nd, vs 3rd trimester pregnancy will have vastly different hemodynamics…intubation is not a benign scenario in the patient presented…and would argue even riskier in a pregnant patient…
Actually pretty calm on ketamine and precedex drips…we do cannulations in non-intubated patients sometimes and have never really had any issues…pt ended up not needing it in the end which is a great thing
well managed when you talk about pk flow are u talking about insp flow rate. My thought is that you would want high Insp. flow at first decreased I time and resp rate increasing E time..enjoy your videos good value for $3/month :-) We met at Haneys course in PR 2019... @@SalimRezaie
