Management of mechanical ventilation in acute severe asthma: practical aspects.
BACKGROUND
Acute severe asthma induces marked alterations in respiratory mechanics, characterized by a critical limitation of expiratory flow and a heterogeneous and reversible increase in airway resistance, resulting in premature airway closure, lung, and chest wall dynamic hyperinflation and high intrinsic PEEP.


CONCLUSIONS
These abnormalities increase the work of breathing and can lead to respiratory muscle fatigue and life-threatening respiratory failure, in which case mechanical ventilation is life-saving. When instituting mechanical ventilation in this setting, a major concern is the risk of worsening lung hyperinflation (thereby provoking barotrauma) and inducing or aggravating hemodynamic instability. Guidelines for mechanical ventilation in acute severe asthma are not supported by strong clinical evidence. Controlled hypoventilation with permissive hypercapnia may reduce morbidity and mortality compared to conventional normocapnic ventilation. Profound pathological alterations in respiratory mechanics occur during acute severe asthma, which clinicians should keep in mind when caring for ventilated asthmatics.


CONCLUSIONS
We focus on the practical management of controlled hypoventilation. Particular attention must be paid to ventilator settings, monitoring of lung hyperinflation, the role of extrinsic PEEP, and administering inhaled bronchodilators. We also underline the importance of deep sedation with respiratory drive-suppressing opioids to maintain patient-ventilator synchrony while avoiding as much as can be muscle paralysis and the ensuing risk of myopathy. Finally, the role of noninvasive positive pressure ventilation for the treatment of respiratory failure during severe asthma is discussed.
Division of Critical Care, Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 11, 1011, Lausanne, Switzerland. Mauro.Oddo@chuv.hospvd.ch
Mauro
M
Oddo
François
F
Feihl
Marie-Denise
MD
Schaller
Claude
C
Perret
D001249:Asthma / Q000503:physiopathology*; D006801:Humans; D007040:Hypoventilation / Q000628:therapy; D012121:Respiration, Artificial / Q000379:methods*; D012720:Severity of Illness Index; D013557:Switzerland