Ketamine in the treatment of bronchospasm during mechanical ventilation

doi:10.1016/0735-6757(94)90051-5

The American Journal of Emergency Medicine

Volume 12, Issue 4, July 1994, Pages 417-420

https://doi.org/10.1016/0735-6757(94)90051-5 Get rights and content

Abstract

The effect of ketamine on bronchospasm during mechanical ventilation was evaluated in a prospective, placebo-controlled, double-blind trial. Fourteen mechanically ventilated patients with bronchospasm were randomly allocated to either ketamine 1 mg/kg or saline placebo. In the ketamine-treated patients, P_O₂ increased from 10.5 (±0.5) kPa to 16.4 (±2.7) kPa (P < .05), whereas P_O₂ in the placebo-treated patients remained unchanged. The P_CO₂ was constant in the ketamine group, although it increased from 5.6 (±0.9) kPa to 6.1 (±0.9) kPa in the placebo group (P < .05). The pulmonary stethoscopic bronchospasm improved immediately after the administration of ketamine, whereas the thoracic compliance remained unchanged. In conclusion, the ketamine-treated patients showed an improvement by stethoscopic examination, in P_O₂ and in P_CO₂, suggesting that ketamine might be useful in the treatment of bronchospasm during mechanical ventilation. However, further studies are required to decide whether ketamine should be considered the drug of choice in patients with severe bronchospasm during ventilator treatment.

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Severe Bronchospasm During Separation from Cardiopulmonary Bypass: Diagnosis, Etiology, and Treatment
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Circuit obstruction, misplacement of the endotracheal tube, and mucous plugging immediately were ruled out, and the patient received nearly every form of therapy for refractory bronchospasm, including endotracheal albuterol and epinephrine, deep volatile anesthetic, intravenous epinephrine and methylprednisolone, and initiation of a propofol infusion. It has been well-described that ketamine can be used for refractory bronchospasm due to its bronchodilatory effects and resulting increase in circulating catecholamines.1,9 Ketamine was considered, but ultimately was not administered, as the patient remained hemodynamically stable on a low-dose epinephrine infusion and the authors wanted to avoid the sympathetic effects and potential increase in pulmonary vascular resistance in the context of a Ross procedure.
High-Risk Airway Management in the Emergency Department. Part I: Diseases and Approaches
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Successful airway management is critical to the practice of emergency medicine. Emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. Challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this first part of a 2-part series.
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Pharmacokinetics of Ketamine at Dissociative Doses in an Adult Patient With Refractory Status Asthmaticus Receiving Extracorporeal Membrane Oxygenation Therapy
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These unique pharmacokinetic and pharmacodynamic properties make ketamine a useful agent for the initial management of severe asthma exacerbations that require intubation. In cases where patients present with severe asthma exacerbations unresponsive to conventional therapy that require emergency intubation, ketamine was reported to improve clinical and laboratory values after repeated administration.12–14 Infusion doses associated with efficacy ranged from 0.75 to 3 mg/kg/h.13–15 These reports may suggest a dose-dependent bronchodilatory response often not seen with subanesthetic doses used in acute pain management.
First-line management of severe asthma exacerbations include the use of inhaled short-acting β-agonists, anticholinergics, and systemic corticosteroids. Continuous intravenous ketamine given at dissociative doses may be a pharmacologic option in patients who are intubated with life-threatening severe bronchospasm unresponsive to standard therapy. We describe the case of a 44-year-old man admitted to the intensive care unit for status asthmaticus requiring intubation and mechanical ventilation.
The patient developed severe refractory hypercapnic respiratory failure necessitating additional respiratory support with veno-venous extracorporeal membrane oxygenation (ECMO) therapy. Ketamine treatment was initiated at 0.5 mg/kg/h continuous infusion on the day of admission for pain control and required up-titration to 2 mg/kg/h by intensive care unit day 4 for bronchodilation. Whole blood samples were obtained for pharmacokinetic analysis of ketamine during ECMO.
The plasma concentration at steady state was 1018.7 ng/mL, with an estimated clearance of 1.96 L/kg/h after up-titration. The V_d was 14.18 L/kg, the k_e was 0.14 hr⁻¹, and the t_½ was 5 hours.
Compared with healthy adults, there was a 6.5-fold increase in the V_d. However, the V_d was similar compared with critically ill patients not receiving ECMO. Further studies should focus on the effect of ECMO on ketamine pharmacokinetic properties.
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In the absence of hypoxemia, ketamine has been shown to have minimal effect on pulmonary vascular resistance in patients with pulmonary hypertension [13]. Although ketamine can act as a bronchodilator, used for refractory bronchospasm [19, 20], its use is associated with laryngospasm [21, 22]. Sevoflurane in 1 or 1.5 MAC concentrations mildly depresses left ventricular systolic function and does not change Qp:Qs in patients with isolated atrial or ventricular septal defects [15].
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^☆: Data were presented at the 66th congress of the International Anesthesia Research Society, San Francisco, CA, March 1992.

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Original contributionKetamine in the treatment of bronchospasm during mechanical ventilation☆

Abstract

Br J Anaesth

Br J Anaesth

Eur J Pharmacol

Ann Emerg Med

Chest

Procaine, lidokaine and ketamine inhibit histamine-induced contracture of guinea pig tracheal muscle in vitro

Anesth Analg

Ketamine in the anesthetic management of asthmatic patients

Anesth Analg

Respiratory mechanics and intrinsic PEEP during ketamine and halothane anesthesia in young children

Anesth Analg

Use of ketamine in an asthamatic child

Anesth Analg

Ketamine hydrochloride in severe bronchospasm

Anaesthesia

Original contribution
Ketamine in the treatment of bronchospasm during mechanical ventilation☆