Ventilation in the crashing asthmatic

Keep sat up and on BIPAP until RSI drugs given, then lie down and apply BVM

Place nasal prongs 15L/min for apnoeic oxygenation providing that placement of this does not break your BVM seal for too long

Avoid vigorously bagging patient once intubated. This will lead to dynamic hyperinflation which  increases the risk of volu/barotrauma and haemodynamic instability

Administer post-intubation paralysis and ensure patient adequately sedated to aid ventilation

Asthmatic patients are notoriously difficult to ventilate and require ventilation strategies, allowing for permissive hypercapnoea

Suggested initial settings:

• SIMV – volume control

• FiO2 1.0

• Respiratory rate 10-12

• TV 6-8ml/kg (ideal body weight)

• Inspiratory flow rate 80-100L/min (allows increased time for expiration)

• PEEP 0-5cm H2O

• I:E ratio 1:4 ideally 

• Plateau airway pressure <30 cmH2O

Useful resources

• ‘Dominating the Vent Part II’, EmCrit Lecture, Scott Weingart