Consequently, critical care physicians encounter patients with status asthmaticus who have failed initial urgent medical treatment and are admitted to the PICU for intensive therapy and monitoring. Subject headings related to asthma, status asthmaticus, critical asthma, and drug therapy were used in a MEDLINE search (1980–2012), supplemented by a manual search of personal files, references cited in the reviewed articles, and treatment algorithms developed within Le Bonheur Children's Hospital.
Picu Status Asthmaticus Epinephrine
D- this patient with status asthmaticus has evidence of severe obstructive lung disease, as evidenced by a large Peak to plateau pressure gradient (36-22=14 cm H20). He also has a large A-E (PaCO2- EtCO2) gradient indicating significant dead space, likely as a result of hyperinflation. Due to this high airway resistance, he needs further time for exhalation. This can be achieved in several ways.
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Picu Status Asthmaticus Treatment
One would be to decrease the respiratory rate. By decreasing the RR from 12 to 10, you increase the total cycle time from 5 seconds (12 breaths per min = 1 breath per 5 seconds while 10 breaths per min = 1 breath per 6 seconds), and thus the E time would increase from 3.5 seconds (5-1.5) to 4.5 seconds (6-1.5). This is not an answer choice though. Increasing the respiratory rate, while theoretically improving minute ventilation, would exacerbate the inability to exhale and thus worsen your hypercarbia and acidosis. In addition, you could decrease the iTime to 1 second, now making your E time 5-1 =4 seconds and your I:E ratio 1:4- This is the correct answer choice D. Inhaled anesthetic is a possibility but would likely be used after ventilator adjustments and other adjuvant medications (heliox, terbutaline, magnesium, aminophylline etc.) had been tried. Increasing the peak pressure risks barotrauma (although mitigated by the high airway resistance since the alveolus only ends up seeing the plateau pressure of 22) while your tidal volumes are likely adequate.
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