Combined ventilator and bicarbonate strategy in the management of status asthmaticus

doi:10.1016/0002-9343(83)91082-3

The American Journal of Medicine

Volume 74, Issue 5, May 1983, Pages 898-901

https://doi.org/10.1016/0002-9343(83)91082-3 Get rights and content

Abstract

Management of intubated hypercapnic asthmatic patients requires a delicate balance between the control of pH with adequate ventilation and the risk of barotrauma associated with the high pressures that may be required. The present report documents a strategy of mechanical ventilation combined with infusion of large amounts of bicarbonate in three patients with severe status asthmaticus requiring intubation. This strategy reduced peak inflation pressure by decreasing ventilation and maintained a physiologic pH while allowing pCO₂ to remain elevated.

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Cited by (88)

Alkali Therapy for Respiratory Acidosis: A Medical Controversy
2020, American Journal of Kidney Diseases
Citation Excerpt :
A special case of such mixed disorder is severe asthma exacerbation resistant to conventional therapy.44,45 In these patients, alkali therapy can result in marked improvement of respiratory distress and a substantial decrease in Paco2.46-50 Alternative measures can cause serious complications (eg, aggravation of lactic acidosis with escalation of β-adrenergic agonists, and pneumothorax and pneumomediastinum with mechanical ventilation).
Alkali therapy for certain organic acidoses remains a topic of ongoing controversy, but little attention has been given to a related medical controversy, namely the prescription of alkali for respiratory acidosis. We first describe the determinants of carbon dioxide retention in the 2 types of respiratory failure; hypercapnic respiratory failure and hypoxemic respiratory failure with coexisting hypercapnia. We then highlight the deleterious consequences of severe acidemia for several organ systems, particularly the cardiovascular and central nervous systems. We argue that alkali therapy is not indicated for respiratory acidosis as a simple acid-base disturbance. Notwithstanding, we recommend prescription of alkali for severe acidemia caused by mixed acidosis (ie, combined respiratory and metabolic acidosis) or permissive hypercapnia. We examine the utility of alkali therapy in various clinical scenarios incorporating respiratory acidosis. We conclude that controlled studies will be required to test the impact of alkali therapy on clinical outcomes of these clinical settings. Such studies should also examine the optimal mode of administering alkali (amount, rate, and tonicity) and the blood pH to be targeted. The development of new buffers should be explored, especially systems that do not generate carbon dioxide or even consume it.
Common Pediatric Respiratory Emergencies
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Citation Excerpt :
With this strategy, Pco2 is allowed to reach up to 70 mm Hg, providing high Fio2 concentrations to maintain saturations greater than 92%, and manipulating ventilator settings (such as the prolonging the expiratory time to allow for complete exhalation) to minimize pressures and avoid barotrauma and other complications. Bicarbonate can be given to correct severe acidosis.87 The decision to hospitalize children with severe asthma depends on the severity of the exacerbation and its response to ED therapy.
Status asthmaticus in the medical intensive care unit: A 30-year experience
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To investigate the characteristics, trends in management (permissive hypercapnia; mechanical ventilation (MV); neuromuscular blockade) and their impact on complications and outcomes in Status Asthmaticus (SA).
We performed a retrospective observational study of subjects admitted with SA to a single multidisciplinary MICU over a 30-year period. All laboratory, radiologic, respiratory care, physician notes and orders were extracted from an electronic medical record (EMR) maintained during the entire duration of the study.
Two hundred and twenty-seven subjects were admitted with 280 episodes of SA. While subjects reflected our regional population (52% Hispanic), African Americans were over-represented (22%) and Caucasians under-represented (21%). Thirty-eight percent reported childhood asthma, 27% were steroid dependent (10% in the last 10 years), and 18% had a recent steroid taper. One hundred and thirty-nine (61.2%) required intubation. The duration of hospitalization was similar between mechanically ventilated and non-ventilated subjects (5.8 ± 4.41 vs. 6.8 ± 7.22 days; p = 0.07). The overall complication rate remained low irrespective of the use of permissive hypercapnia or mode of mechanical ventilation (overall mortality 0.4%; pneumothorax 2.5%; pneumonia 2.9%). The frequency of SA declined significantly in the last 10 years of the study (12.4 vs. 3.2 cases/year).
Despite the frequent use of mechanical ventilation, mortality/complication rates remained extremely low. MV did not significantly increase the duration of hospitalization. At our institution, the frequency of SA significantly decreased despite an increase in emergency room visits for asthma.
Managing Asthma Exacerbations in the Emergency Department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbations
2009, Journal of Emergency Medicine
Citation Excerpt :
In addition, high ventilator pressures, with their associated risks of barotrauma, should be avoided. “Permissive hypercapnia” or “controlled hypoventilation” is the recommended ventilator strategy because it provides adequate oxygenation while minimizing airway pressures and the possibility of barotrauma (44–46). However, this strategy is not uniformly successful in critically ill asthmatic patients, and additional therapies are under evaluation.
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¹: From the Department of Medicine and Chest Service, N.Y.U.-Bellevue Medical Center, New York, New York.

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Report on therapyCombined ventilator and bicarbonate strategy in the management of status asthmaticus

Abstract

Am J Med

Am J Med

Am J Med

Clin Chest Med

The use of sodium bicarbonate in the treatment of acute bronchial asthma

N Engl J Med

Bicarbonate therapy in severe acute respiratory acidosis

Scand J Respir Dis

Report on therapy
Combined ventilator and bicarbonate strategy in the management of status asthmaticus