Status asthmaticus (SA) is defined as an acute, severe
asthma exacerbation that does not respond readily to initial intensive
therapy, while near-fatal
asthma (NFA) refers loosely to a
status asthmaticus attack that progresses to
respiratory failure. The in-hospital mortality rate for all asthmatics is between 1% to 5%, but for
critically ill asthmatics that require intubation the mortality rate is between 10% to 25% primarily from
anoxia and
cardiopulmonary arrest. Timely evaluation and treatment in the clinic, emergency room, or ultimately the intensive care unit (ICU) can prevent the morbidity and mortality associated with
respiratory failure. Fatal
asthma occurs from
cardiopulmonary arrest,
cerebral anoxia, or a complication of treatments, e.g.,
barotraumas, and
ventilator-associated pneumonia. Mortality is highest in African-Americans, Puerto Rican-Americans, Cuban-Americans, women, and persons aged ≥ 65 years.
Critical care physicians or intensivists must be skilled in managing the
critically ill asthmatics with
respiratory failure and knowledgeable about the few but potentially serious complications associated with
mechanical ventilation.
Bronchodilator and anti-inflammatory medications remain the standard
therapies for managing SA and NFA patients in the ICU. NFA patients on
mechanical ventilation require modes that allow for prolonged expiratory time and reverse the dynamic hyperinflation associated with the attack. Several adjuncts to
mechanical ventilation, including
heliox,
general anesthesia, and extra-corporeal
carbon dioxide removal, can be used as life-saving measures in extreme cases. Coordination of discharge and
follow-up care can safely reduce the length of
hospital stay and prevent future attacks of
status asthmaticus.