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K. G. Correa and L. E. Eggert
Studies have not shown a benet of using nebulizers over MDIs; however, MDIs are
more cost effective [9]. More doses of an MDI are required to reach an equivalent
dosage of medication in a nebulized solution [9]. A meta-analysis and systematic
review evaluated the benet of addition of SAAC to SABA monotherapy in acute
asthma. The results consistently demonstrated that combination usage of SABA/
SAAC, at single or multiple doses, was more effective at reducing the risk for hospitalization and improving lung function than either medication alone [10, 11].
Dosages and frequencies for inhaled medications varied in the studies; however,
ranges included albuterol 2.5–5 mg from hourly to several times per hour, and
ipratropium 0.5mg with similar frequency. In the ICU, inhaled bronchodilators are
usually started as a continuous nebulization and then are spaced out as the patient
improves clinically.
7.3.2 Indications forAntibiotics
Bacterial infections as triggers for asthma exacerbations only make up as small
number of total exacerbations [12]. However, starting empiric antibiotics remains a
common practice among providers [12]. Several studies have been published investigating whether the addition of antibiotics to the standard of care improves outcomes in asthma exacerbations. These studies excluded patients with conrmed
bacterial infections warranting antibiotics. In a meta-analysis and systematic review
of these studies, there was limited evidence to suggest that the addition of empiric
antibiotics improved symptoms or airow obstruction [12, 13]. The antibiotic
classes that were studied included macrolides and penicillins, and there was no difference in outcomes by antibiotic class. However, like prior studies, patients admitted to the ICU were excluded from these studies. In cases of severe asthma requiring
ICU admission, antibiotic coverage is usually initiated empirically, and then the
decision to continue is readdressed after reviewing preliminary data to better rule in
or rule out infection.
In addition to white blood cell count and culture data, serum procalcitonin measurements have been explored in asthma to guide the initiation and discontinuation of
antibiotics. Procalcitonin, a pre-hormone to calcitonin, rises with bacterial infections
but not with viral infections and has been studied extensively in relation to airway
infections [5]. In one randomized, controlled trial, the procalcitonin level was used to
decide whether to initiate and when to discontinue antibiotics versus clinician discretion. The group where procalcitonin levels were used to guide decisions on antibiotics
had reduced the use of antibiotics without differences in clinical outcomes [14]. While
it is not available in all health systems, serum procalcitonin may be of assistance when
making decisions regarding antibiotic initiation and/or discontinuation.
7 Acute Asthma Exacerbation intheIntensive Care Unit
161
7.3.3 Potential Adjunctive Therapies
7.3.3.1 Inhaled Corticosteroids (ICSs)
ICSs are the mainstay of the management of outpatient asthma; however, they play
a limited role in the management of acute asthma exacerbations [2, 15]. This is
largely due to the use of enteral or intravenous corticosteroids that are at doses much
higher than the inhaled form can deliver. However, one argument that is made for
the use of ICS is immediate delivery to the affected region [15]. Previous studies
evaluating the use of ICS in acute asthma exacerbations have primarily looked at the
use of adjunctive ICS to prevent hospitalization, and in most studies, the need for
ICU admission or status asthmaticus was an exclusion criterion. In a pooled metaanalysis
addition to systemic corticosteroids, resulted in decreased hospital admissions [15].
Further studies analyzing the benet of ICS on other important outcomes and in
more severe exacerbations are needed. Adjunctive ICS use combined with systemic
corticosteroids should be considered for use in patients with severe asthma exacerbations in the ICU in addition to standard-of-care therapy, especially since they are
generally well tolerated with minimal potential for adverse effects.
and systematic review, ICS use in acute asthma, either versus placebo or in
7.3.3.2
venous (IV) Magnesium Sulfate (MgSO
Intra
)
4
The use of IV magnesium sulfate has been well described as an adjunctive treatment
for severe asthma when there is clinical deterioration despite the initiation of
standard- of-care medications [5, 16]. Its mechanism of action is still unclear, but it
is believed that magnesium sulfate promotes bronchial wall smooth muscle relaxation and may also mitigate airway inammation [16]. In a meta-analysis of
placebo- controlled trials evaluating the efcacy of a one-time bolus of IV magnesium sulfate, its use resulted in a reduced need for hospital admission and improved
lung function [16]. Of the studies available, only one study evaluated the effect of
IV magnesium sulfate on the need for admission to the ICU, which did not show any
signicant difference compared to placebo [16]. Nonetheless, a one-time bolus of
IV magnesium sulfate should be considered in all patients being admitted to the
ICU for severe asthma given potential benets and lack of signicant adverse
effects.
7.3.3.3 Inhaled Magnesium Sulfate (MgSO
)
4
While the use of IV magnesium sulfate is well described and frequently used in
clinical practice, the use of inhaled magnesium sulfate is less common. The nebulized solution is prepared by diluting the IV formulation or dissolving MgSO4 into
sterile water; however, there are no FDA-approved formulations of nebulized magnesium sulfate currently available [17]. The use of inhaled magnesium sulfate has
162
K. G. Correa and L. E. Eggert
been investigated in asthma refractory to the initial standard of care. In a review of
trials investigating the benet of inhaled magnesium sulfate in addition to SABA/
SAAC, doses of inhaled magnesium sulfate ranged from one to three (spaced out by
30-min intervals) [17]. Another meta-analysis of seven studies showed varying
results, and the authors concluded that there may be a small benet to the addition
of inhaled magnesium sulfate, with a low condence level [17]. Given the relative
safety of the medication, its use could be considered in life-threatening circumstances in areas where it is available for use.
7.3.3.4 Intravenous (IV) Aminophylline
Aminophylline belongs to the drug class of methylxanthines, which includes theophylline. Both medications have historically been used for the treatment of chronic
asthma for their weak bronchodilator effects. They have since been mostly replaced by
stronger bronchodilators such as inhaled beta2-agonists [18]. IV aminophylline has
been proposed as an adjunct to inhaled beta2-agonists in the treatment of acute asthma.
A meta-analysis of 17 studies did not show any signicant improvement in airow or
need for systemic corticosteroids with the use of IV aminophylline [18]. Additionally,
patients treated with aminophylline experienced a higher incidence of nausea, vomiting, palpitations, and/or arrhythmias [18]. Because of these potential side effects and
minimal evidence for benet, IV aminophylline should be avoided in patients experiencing severe asthma requiring ICU admission. Nausea and vomiting may increase the
risk for aspiration in patients and may also predispose them to dangerous arrhythmias
when used in combination with SABAs.
7.3.3.5 Intravenous (IV) Beta2-Agonists
The use of inhaled beta
-agonists is the standard of care in acute asthma; however,
2
the IV formulations of these drugs, such as bedoradrine and terbutaline, are rarely
used. These drugs have mostly been studied in pediatric patients, in which there was
no difference in the rates of ICU admissions with or without the drug [19]. Only one
study has looked at the addition of IV beta2-agonists to the standard of care in adult
patients, and it did not lead to a reduction in hospital admissions [19].
7.3.3.6 Leukotriene Antagonists (LTRAs)
LTRAs such as montelukast are commonly used in the outpatient setting for the
management of allergic asthma [2]. Production of leukotrienes by the immune system as a response to allergic triggers leads to bronchoconstriction and subsequent
asthma symptoms [20]. Several studies have evaluated the impact of LTRAs in
acute asthma as adjuncts to standard-of-care therapy. A meta-analysis showed a
small improvement in airow but no signicant difference in hospital admission
7 Acute Asthma Exacerbation intheIntensive Care Unit
163
rates with IV or oral LTRAs. There was a slight, although nonsignicant, trend
towards a reduction in hospital admissions in the IV group [20]. However, there are
currently no FDA-approved IV LTRAs available commercially.
7.3.3.7 Intramuscular (IM) or IV Epinephrine
As highlighted in the earlier sections, anaphylaxis may mimic a severe asthma exacerbation. Untreated, both have a high mortality rate, and early recognition and
appropriate treatment are paramount. IM epinephrine is the standard-of-care treatment for anaphylaxis. Epinephrine activates both alpha- and beta-adrenergic receptors and therefore could potentially be used in acute asthma exacerbations. A
previous meta-analysis included studies in which epinephrine was administered in
any formulation to patients with acute asthma exacerbations [21]. Epinephrine was
found to be similarly efcacious to selective beta2-agonists, but epinephrine had
more side effects, and there was no clinical benet when any form of epinephrine
was added to inhaled beta2-agonists in acute asthma [21]. Therefore, there is no data
to support the use of epinephrine for severe asthma in the ICU aside from in patients
with concomitant conrmed or suspected anaphylaxis.
7.3.3.8 Inhaled Anesthetics
Inhalational anesthetics such as isourane have been studied in patients with severe
asthma requiring invasive mechanical ventilation [22]. Inhalational isourane stimulates the beta-adrenergic receptor leading to bronchial wall smooth muscle relaxation and bronchodilation [22]. In the limited number of cases in which isourane
has been used, patients had generally already received many of the adjunctive therapies previously discussed. Clinical improvement was reported in all patients receiving isourane therapy, with a duration of therapy ranging from 16 to 34hours [22].
Pursuant to local hospital policy, the presence of an anesthesiologist may be required
when using inhaled isourane.
7.3.3.9
Inhaled Helium-Oxygen (Heliox)
The combination of oxygen-helium mixtures has long been used for patients with
se
vere asthma exacerbations given that it reduces airway resistance [23, 24]. It has
been studied in both mechanically ventilated patients and non-ventilated patients.
For patients with acute asthma exacerbations not requiring mechanical ventilation,
placebo-controlled trials have not demonstrated improved outcomes with heliox
[23]. However, the primary outcomes in many of these studies were limited to rates
of hospital admission and did not assess more seriously ill patients. One prospective
observational study evaluated heliox in patients requiring mechanical ventilation for
asthma or COPD exacerbations (high airway resistance states), without demonstrable improvement in measures of airway resistance [24].
164
7.3.3.10 Intravenous Ketamine
Ketamine has been used as an adjunct for severe asthma when there is clinical
deterioration despite standard-of-care therapy [25]. Ketamine has many properties
with potential benet in severe asthma. It acts as a direct bronchodilator, stimulating beta2-adrenergic receptors, and has indirect bronchodilator effects through the
inhibition of vagal stimulation that leads to bronchoconstriction [25]. Data supporting the use of IV ketamine as an adjunctive therapy for severe asthma in the ICU
come primarily from case reports. There is some data that ketamine, when given as
an infusion, reduced the risk for requiring mechanical ventilation. In mechanically
ventilated patients who received ketamine, improvement in clinical status and
decreased airway resistance have been reported [25]. The limited data available
suggests that IV ketamine is one of the few adjunctive therapies which may be
particularly benecial in patients with severe asthma requiring ICU admissions.
High-quality studies are needed to validate these benets. Also, this is another
medication which may require the presence of an anesthesiologist for
administration.
K. G. Correa and L. E. Eggert
7.3.4 Emerging andInvestigational Therapies
7.3.4.1 Subcutaneous (SC) Biologics
Biologics in asthma are a relatively new therapy. These monoclonal antibodies target cytokines in the Th2 inammatory pathway and are used in the outpatient setting
to treat patients with uncontrolled asthma symptoms or frequent exacerbations
despite maximal inhaler therapy [26]. The role of these therapies in acute asthma is
unknown. In one patient case, the biologic dupilumab was used as an adjunct for an
asthma exacerbation that did not respond to the standard of care. Following SC
administration of dupilumab, there was notable patient improvement [26]. Given the
low side effect prole and potential benets of these medications in acute asthma
exacerbations, further studies are needed evaluating these therapies in the acute
setting.
7.4 Airway Management ofExacerbations
ICU admission and the need for mechanical ventilation are associated with
increased morbidity and mortality in patients with severe asthma exacerbations
[27]. Therefore, it is crucial to promptly identify patients at risk for progressive
respiratory failure. Asthma is a disease of the airways, and hypoxemia is not
typically present in most asthma exacerbations [5]. In many cases, patients do
7 Acute Asthma Exacerbation intheIntensive Care Unit
165
not require high amounts of supplemental oxygen, and providers should aim to
keep oxygen saturation >92% [5]. Impending respiratory failure is often signaled
by respiratory muscle fatigue, mental status changes, lethargy, or hypercapnia
and should be promptly treated with noninvasive or invasive ventilatory support [5].
7.4.1 Noninvasive Ventilation (NIV)
The use of NIV in severe asthma may help to provide enough respiratory support to
stave off the need for intubation and mechanical ventilation. NIV can assist with
alleviating the patient’s work of breathing and correcting hypercapnia that may lead
to CO2 narcosis—a common cause of intubation in delayed presentations of severe
asthma exacerbations [4]. Modalities of NIV include continuous positive-pressure
ventilation (CPAP) and bilevel positive pressure ventilation (BiLevel). For severe
asthma exacerbations, bilevel pressure support ventilation is preferred and titrated
at the discretion of the intensivist to augment ventilation [4, 27]. Support for the use
of NIV in severe asthma exacerbations is mostly coopted from the literature supporting the use of NIV in COPD exacerbations, which are similar physiologically to
asthma exacerbations [27]. A large, multicenter, cohort study evaluating outcomes
of NIV use in severe asthma exacerbations found that its use was associated with a
reduction in the need for invasive mechanical ventilation and also a small mortality
benet [27]. NIV should be considered for appropriately selected patients with
severe asthma exacerbations in the ICU.
7.4.2 Invasive Mechanical Ventilation (IMV)
Progression of an asthma exacerbation to IMV is concerning and indicates severe
disease. This severe state is notable for high airway resistance (P
tion [28, 29]. Intensivists and respiratory therapists should closely monitor the airway resistance and auto-PEEP, a marker for hyperination [29, 30]. Medication
adjuncts can be considered if there is limited response to standard of care while
patients receive IMV. Downstream complications of uncontrolled hyperination
and high airway resistance include barotrauma, pneumothorax, and hypotension
[29, 30]. Deep sedation may be required to address ventilator dyssynchrony until
improvement in respiratory dynamics. If unable to obtain ventilator synchrony
despite sedation, paralytics may be considered [29]. Once improved from a respiratory status, mechanical support and sedation should be weaned as tolerated by the
patient. Extubation should be considered once there has been signicant improvement in disease state (Fig.7.3).
) and hyperina-
peak
166
Fig. 7.3 Ventilator screen demonstrating obstruction and auto-PEEPing in an asthmatic patient
K. G. Correa and L. E. Eggert
7.5 Extracorporeal Membrane Oxygenation (ECMO)
inExacerbations
ECMO is a form of mechanical circulatory support that can be used to support
patients with profound hypoxemic respiratory failure and/or cardiovascular failure.
It functions by removing blood via a drainage cannula inserted either in a central
vein or in an artery, passing it through an oxygenator and pump and then delivered
back into the body via a return cannula [31]. The conguration of ECMO is determined by the disease state and the amount of support required by the patient [31].
The use of ECMO for refractory severe asthma is rare; however, it has been described
in the literature as salvage therapy when invasive mechanical ventilation was insufcient. There is limited evidence to support the use of ECMO as salvage therapy. A
retrospective, cohort study evaluating 127 asthma exacerbations requiring ECMO
support demonstrated an association with lower mortality in the ECMO group versus propensity-matched models [31]. While further studies are required to explore
this subject, ECMO as a rescue modality can be considered if there is further clinical deterioration despite maximal patient optimization following the initiation of
invasive mechanical ventilation.
7 Acute Asthma Exacerbation intheIntensive Care Unit
167
7.6 De-escalation ofCare
As an asthma exacerbation improves, the patient will note improved work of breathing, reduced cough, resolution of wheezing, and improved air movement on auscultation. Corticosteroids should be transitioned to oral when tolerated and continued
until at least discharge, if not continued as a slow taper through outpatient follow up. Use of SABAs and SAACs should be spaced out from continuous to every few
hours and then used on an as-needed basis. Near discharge, patients should be
restarted on their home ICS if not continued during hospitalization. If a patient was
not previously on an ICS, this should be started prior to discharge and continued
until outpatient follow-up. The GINA guidelines are a helpful resource for identifying an ideal inhaler regimen for a patient. Inhaler teaching should occur with a
respiratory therapist before discharge, and patients should be given a spacer if
appropriate and instructed on its use.
7.6.1 Outpatient Follow-Up
Patients who require admission for an asthma exacerbation should be referred to a
pulmonologist as an outpatient [5]. Inhalers and medications should be reconciled
based on symptoms, and triggers should be reviewed to prevent future exacerbations. In certain cases, patients with severe asthma exacerbations are discharged on
a tapered oral corticosteroid regimen that should be carefully discontinued.
Symptoms may return if corticosteroids are weaned too quickly. If asthma symptoms remain persistent and severe despite maximal inhaler therapy requiring oral
steroids, addition of biologics should be considered.
7.7 Summary
Asthma is an inammatory disease of the respiratory airways that results in symptoms of shortness of breath, wheezing, and cough. Mainstay therapy of outpatient
asthma is through inhaled corticosteroids and bronchodilators. An asthma exacerbation is dened by acute worsening of asthma symptoms, and it requires escalation
of care to properly manage. Exacerbations can be triggered by infectious and noninfectious etiologies. The standard of care in an asthma exacerbation is centered
around corticosteroids and frequent administration of bronchodilators. Exacerbations
can be severe and progress to profound respiratory failure requiring the ICU.Several
adjunct therapies have been studied in severe asthma that does not initially respond
to the standard of care, each with varying levels of efcacy. Respiratory status
should be closely monitored with the goal to avoid invasive mechanical ventilation
168
K. G. Correa and L. E. Eggert
as it carries an increased risk for mortality. Studies show some mortality benets
with using noninvasive ventilation to prevent the need for invasive mechanical ventilation. Once improved and discharged, patients with a history of an asthma exacerbation requiring ICU admission are considered high risk and should have close
outpatient pulmonology follow-up.
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