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Medical emergency when bronchospasm is refractory to bronchodilator and steroids in the ED.

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High-risk predictors:

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  • Previous severe exacerbation (e.g., intubation or ICU admission for asthma)
  • Two or more hospitalizations for asthma in the past year
  • Three or more ED visits for asthma in the past year
  • Hospitalization or ED visit for asthma in the past month
  • Using >2 canisters of short-acting beta-2-agonist per month
  • Attack while under systemic steroids, or recent discontinuation of steroids
  • Difficulty perceiving asthma symptoms or severity of exacerbations, noncompliance

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Table Graphic Jump Location
Table 205-1 Special Considerations for Anesthesia 
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Signs of severity:

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  • Cyanosis, profuse sweating, mental status changes
  • Bradycardia, hypotension, pulsus paradoxus >15 mm Hg
  • Accessory muscle use, silent chest, difficulty speaking, inability to lie down
  • Peak expiratory flow rate (PEFR) <200 L/min and/or <40% predicted/usual value
  • FEV1 <40% of predicted is an ominous sign in an adult
  • Room air SpO2 <92%, PaO2 <60 mm Hg, Paco2 >45 mm Hg

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See Table 205-2 for drug dosages.

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  • Oxygen: keep SaO2 ≥92% (>95% in pregnancy)
  • Inhaled nebulized beta-2-agonist: albuterol
  • Inhaled nebulized anticholinergic agent: ipratropium bromide, along with albuterol
  • Steroids: methylprednisolone, dexamethasone, or hydrocortisone, IV, IM, or even PO:
    • Give steroids early as peak action delayed by 3–4 hours
  • Monitor K; replete as needed: both beta-agonists and steroids cause hypokalemia
  • If high-risk predictors, signs of severity, no improvement after first treatment, transfer to ICU
  • Magnesium sulfate IV if no resolution after 1 hour of continuous nebulization and steroids, or as first line if signs of severity
  • Terbutaline or epinephrine (never both) after 1 hour of nebulization and steroids
  • Heliox-driven albuterol nebulization after 1 hour of continuous nebulization and steroids. It decreases work of breathing and improve ventilation (but may lower O2)
  • Ketamine is sometimes helpful when everything else fails before intubation
  • Intubate with rapid sequence if:
    • Lethargic
    • Unable to maintain airway
    • Slow respiratory rate
    • PCO2 normal or high
  • If intubated:
    • Vt 5–7 mL/kg, RR 6–8/min, I:E ...

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