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Life-Threatening Asthma
19 Plays1 year ago
In this episode, Dr. Zanotti discusses the management of acute life-threatening asthma exacerbations in the ICU with this guest, Dr. Haney Mallemat, a physician trained in EM/IM and Critical Care. Dr. Mallemat is currently an Associate Professor of Emergency Medicine and Internal Medicine at the Cooper Medical School at Rowan University.
Additional Resources:
How Not to Kill an Asthmatic – Presented at CODA Change by Haney Mallemat: https://codachange.org/severe-asthma
Management of Acute Life-Threatening Asthma Exacerbations in the Intensive Care Unit. Talbot T, et al. Appl. Sci 2024: https://www.mdpi.com/2076-3417/14/2/693
ResusX,- a medical resuscitation conference created by Dr. Mallemat: https://www.resusx.com
Last Week Now! - A curated newsletter by ResusX: https://www.resusx.com/newsletter
Keynotable – a course for beginners and seasoned speakers: https://www.keynotable.net
Books mentioned in this episode:
How to Win Friends and Influence People. By Dale Carnegie: https://bit.ly/49WlcOd
Recommended
Transcript
Introduction to Critical Matters
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
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Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
Challenges in ICU Management of Acute Asthma
00:00:32
Speaker
Managing acute asthma exacerbations in critical care can be challenging and may lead to adverse outcomes.
00:00:38
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Extensive research and guidelines focus on the outpatient and ED management of asthma.
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However, the management of life-threatening asthma in the intensive care unit still needs to be fully defined.
00:00:49
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Today's podcast episode will focus on the critical care management of life-threatening asthma.
Guest Introduction: Dr. Haney Malamud
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Our guest is Dr. Haney Malamud.
00:00:56
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a physician trained in EM and IM and critical care medicine.
00:01:00
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Dr. Malomet is currently an associate professor of emergency medicine and internal medicine at the Cooper Medical School at Rowan University.
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Dr. Malomet is a master medical educator with a large social media audience.
00:01:12
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In the last years, Dr. Malomet has created a medical resuscitation conference called ResusX, which focuses on cutting edge education and resuscitation and critical care.
00:01:21
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He also posts and curates a free resuscitation blog called Critical Care Now.
00:01:26
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Finally, Dr. Malamud's dedication to the art of presentation and slide design has led him to create a course for beginners and seasoned speakers called Key Notable.
00:01:37
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Haney is a good friend of the podcast and has been on several times.
00:01:40
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Haney, welcome back to Critical Matters.
Why Intensivists Should Care About Life-threatening Asthma
00:01:43
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Thanks for having me, Sergio.
00:01:44
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It's always a pleasure to talk to you.
00:01:46
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Same here.
00:01:47
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So today we're going to talk about life-threatening asthma.
00:01:51
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And obviously, as a clinician who is trained in emergency medicine, internal medicine, and critical care, and who works in the ED and in the ICU, you get to see some of these very, very, very extreme cases of life-threatening asthma.
00:02:05
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So my question to you, Haney, is why should intensivists care about life-threatening asthma?
00:02:11
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It's a great question because most of the patients that I think we'll be talking about today have already been seen in the emergency department.
00:02:19
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A lot of the things we'll talk about have already been matched in the emergency department.
00:02:23
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However, I have had a few scenarios where patients have come in and developed
00:02:29
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an acute asthma exacerbation.
00:02:31
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And then the other thing to remember is that anaphylaxis and severe asthma can sometimes share borders.
00:02:38
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And so you might have a patient who you're managing in the ICU and they develop severe anaphylaxis.
00:02:43
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And some of the things that we'll be talking about will be very applicable to these patients.
Alternative Treatments for Severe Asthma
00:02:50
Speaker
Perfect.
00:02:50
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And in terms of introduction, what are some relevant pathophysiology concepts of severe asthma that might be important for our discussion today?
00:03:00
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I think the biggest thing to remember, you know, without going into too much detail about like mast cells and histamine, the biggest thing to remember is that these severe asthmatics, they're severely bronchoconstricted.
00:03:13
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And some of the traditional medicines that we start to use or we typically use in asthmatics may not work in these patients.
00:03:20
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I'm speaking specifically about our inhaled agents like albuterol and ipotropium.
00:03:26
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Those agents might not get to the target mucosa because of severe bronchocontriction.
00:03:31
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And we'll talk about some of the things that you can do for those people.
00:03:35
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Perfect.
00:03:37
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When you first see encounter a patient, the initial assessment, how do you evaluate the severity of their acute asthma attack?
00:03:46
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When I started training, it used to be doing peak flows on patients.
00:03:49
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And as I got on my career and the literature shown, it's just really more clinical.
00:03:54
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I mean, the patient with severe asthma, it's very, very obvious when you walk in the room.
00:03:59
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They're tripodting, they're retracting, they're speaking in one to two word phrases.
00:04:06
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You listen to their chest.
00:04:08
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They may have severe wheezing or even worse, they just might have a silent chest.
00:04:13
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And all those factors go into the impression that this person is having a severe life-threatening asthma attack.
00:04:19
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It's time to get to business.
00:04:21
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Now, you mentioned peak expiration flows.
00:04:24
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Is there any value in tracking those?
00:04:26
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I mean, as we treat patients or they're just, I mean, when somebody is really in severe status of that, because it's just very difficult to get them.
00:04:35
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They're, first of all, difficult to get because you need a patient who's going to participate.
00:04:40
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And they're not very helpful in terms of the management.
00:04:43
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Again, this is going to be a clinical management where you're following the patient at the bedside and you're just relying on your exam and how the patient is looking.
00:04:51
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So I would rather not waste time in trying to coach the patient to get some number that's going to be meaningless to me and start giving that patient therapy.
Criteria for ICU Admission in Asthma Cases
00:05:02
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How do you decide if somebody needs to go to the ICU?
00:05:06
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Well, in terms of a severe asthma exacerbation, it's really what happens after the treatment.
00:05:14
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If the person is on a non-invasive or they're requiring continuous nebulization, I need a nurse to be watching that person like a hawk to see if they're going to be decompensating.
00:05:25
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So short of intubation, you know, all the things that tell me that the person isn't out of the woods would lead me to put the person in an ICU.
00:05:34
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That is obviously a unique aspect because some asthmatics might show looking extremely, extremely ill, but if they respond to therapy very quickly in the ED, they might not need to go to the ICU.
00:05:46
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But those who are not responding are the ones that really we should be worried about.
00:05:50
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Yeah, there are people who...
00:05:53
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you know they they come in they look terrible they almost look like they're going to die and if you're aggressive early on with these asthmatics i've sent these people to the floor which is always comical when you're talking to the hospitalists on the phone they're like this person was on non-invasive you gave epinephrine they were on an epi drip and now you're sending them to the floor and uh in some rare cases these patients can turn around pretty quickly
00:06:16
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But I will say that, you know, when someone comes in who's looking so deathly ill, they're going to be with me for a few hours in the ED before even considering that hospitalist move.
00:06:25
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More often than not, they're probably going to go to some step-down level of care just to observe them for overnight or for the next 12 hours.
00:06:33
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There's something called the Lindy effect.
00:06:35
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I don't know if you're familiar with it, but basically it's the actual length of anything predicts its actual half-life most likely.
00:06:45
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So for example, they used to talk about shows on Broadway, like if a Broadway show has been on
00:06:50
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For years, it probably will be on for another couple of years, right?
00:06:54
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And I think of asthma attacks sometimes in the Lindy effect.
Essential Medications for Severe Asthma
00:06:57
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If somebody gets really sick really quickly, there's a good chance that you could get them better really quickly.
00:07:03
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However, those who've been festering for a couple of days and get really sick, probably going to take a little bit longer.
00:07:08
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Is that something that you have validated or seen in your own experience?
00:07:12
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I can't say that I have.
00:07:14
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To be honest, there have been people who have come in with severe life-threatening asthma, who have even been intubated, who have really had nothing more than a benign asthma attack at home or even just an acute exacerbation.
00:07:28
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So that sort of prodrome that we see in most other diseases, like someone with severe sepsis, you can track them back and see they've been sick for a few days before that.
00:07:38
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I haven't seen it consistently with asthma, but
00:07:41
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for the next couple of people I see with it.
00:07:44
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So I'll get back to you on that.
00:07:45
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Let me know.
00:07:46
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So let's talk about pharmacological therapy and maybe we can start just to categorize.
00:07:50
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Obviously, when these patients come into the ED, a lot of things are going on, but let's just start with a framework of talking about what are the initial drugs that you would recommend every severe asthmatic get?
00:08:04
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There are drugs that people are going to get, which are the sort of routine package of asthma that every asthmatic gets.
00:08:12
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And that's going to be continuous nebulization with albuterol and ipotropium.
00:08:17
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They're going to be getting steroids intravenously because they're in respiratory distress, even though the bioavailability and the mechanism of action arguably is equal to oral.
00:08:27
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But because of the respiratory stress, they're going to get intravenously.
00:08:29
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And then there's the magnesium dosing, which again has been controversial over the course of the past few years.
00:08:36
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But I think for anyone who's having severe life-threatening asthma, giving magnesium as a bronchodilator would be very prudent.
00:08:42
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So those are the medications that are given routinely, I would say.
00:08:48
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I think the next thing we need to go to is the medications that we don't often think about as being associated with severe life-threatening asthma.
00:08:55
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And the first one of those that we'll stop and we'll talk about is using epinephrine.
00:09:00
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And we're talking about epinephrine intramuscularly in the anaphylactic dose of 0.3 to 0.5 milligrams IM, and then rapidly progressing to intravenous.
00:09:11
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And the reason why I think that's so important, and I
00:09:14
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when I see people who get intubated in the emergency department, I find that people are not aggressive about giving epinephrine.
00:09:22
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The reason why it's so important is because remember,
00:09:25
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As I alluded to before, that albuterol, that ipotropion, is not getting to its target organ in someone who's a really tight clamped down asthmatic.
00:09:33
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And so all that albuterol you're giving is maybe just hitting the trachea in the dead space.
00:09:38
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What I want to do is I want to get that beta agonist effect of epinephrine, and that we're going to give it intramuscularly and intravenously to get to target organs to break that bronchoconstriction.
00:09:50
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And in terms of other intravenous beta agonists, the studies haven't really shown that they're much better than using albuterol, but epinephrine up front, like you said, is probably something that we should consider for those sicker patients.
00:10:08
Speaker
Yeah, I think in Australia, you know, they have intravenous albuterol, and that's fine, but we don't have that.
00:10:14
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And
00:10:15
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And terbutylene will come up as people will say, well, why don't you just use terbutylene?
00:10:19
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I think terbutylene is just fine.
00:10:21
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But I believe that you should be using drugs in your department that clinicians and nurses are familiar with.
00:10:27
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And if you're saying that epinephrine is equal to butamine, why not use a drug that you use every day, you have a familiarity with, and you know the dosing and how to run drips.
00:10:36
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That's why I go with epinephrine.
00:10:38
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And there are studies that show, by the way, that people will sometimes get afraid of epinephrine because they say, oh, the person's tachycardic or they're hypertensive.
00:10:47
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I don't want to make them more tachycardic and more hypertensive.
00:10:51
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On first glance,
00:10:52
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That
Early Aggressive Treatment Strategies
00:10:53
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makes a lot of sense.
00:10:54
Speaker
However, when you think about it, that person's tachycardic and hypertensive because they feel like they're going to die.
00:11:00
Speaker
And there's studies, albeit from the 70s and the 80s, that show that for these severe asthmatics, giving them epinephrine actually reduces their tachycardia and their hypertension because those patients can breathe again and they don't feel like they're going to die.
00:11:14
Speaker
And I think that probably one important take home that says here is that if somebody is really sick and is not responding very quickly to the initial the initial therapy that you mentioned, using epinephrine early, right?
00:11:27
Speaker
In the first, I mean, I would say hour of somebody being treated is probably the way to go.
00:11:33
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Is that correct?
00:11:35
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Absolutely.
00:11:35
Speaker
The pitfall that I see is that people give some nebs and then they wait a little bit and they give some other nebs and they wait a little bit and they're hopeful.
00:11:42
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And we all have to have hope, but we also have to know the progression of the disease.
00:11:46
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When someone comes in looking like this, have a very low threshold to progress rapidly because something we'll be talking about through the rest of this podcast is that these patients' respiratory muscles, they basically have a stopwatch when they hit the door.
00:12:01
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And what I mean by that is they're going to fatigue at some point.
00:12:05
Speaker
And so I would rather be aggressive way up front with that person while those muscles are fatiguing so that we get some hope that we don't have to intubate this patient.
00:12:13
Speaker
If you wait too long and do some of the other therapies that are not as aggressive, even though this
00:12:19
Speaker
they're going to fatigue.
00:12:20
Speaker
And even though those steroids and everything else might kick in a little later, it might be too late because the fatigue has set in.
00:12:28
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And I reminded myself to tell you one more thing.
00:12:30
Speaker
When we said continuous nebulization in the front of the podcast, I mean, they really have to be making a lot of smoke in the room.
00:12:39
Speaker
Like if I walk into someone's room and it doesn't look like a college dorm room
00:12:43
Speaker
filled with lots of smoke, then I know they're not getting enough continuous nebulization.
00:12:47
Speaker
They need to be putting out a lot of smoke in that room, a lot of nebulization for me to know that we're maximizing our nebulization effect.
00:12:56
Speaker
And let's just, before we move on to airway management, dissect a little bit more of the usual medications to make sure that everybody's on the same page.
00:13:04
Speaker
So like you said, I mean, we start with a beta-2 agonist, which is a butyrol, and you use them as continuous nipotations.
00:13:11
Speaker
So you're giving them one, two, three in a row, right?
00:13:14
Speaker
One after another.
00:13:15
Speaker
And like you said, very aggressively.
00:13:17
Speaker
That's the way you would start.
00:13:19
Speaker
Yeah, I get like a, before respiratory comes down and gets a continuous setup, you know, you just take as many of those duonebs, you put them into the nebulizer and you just let it go.
00:13:30
Speaker
And that's why I said, you just got to make smoke.
00:13:31
Speaker
People are so concerned about, let's put a neb in and let's see what happens.
00:13:35
Speaker
You put as many of those, those, the duonebs in, the beta-2 agonist, the muscarinic, you put them in and you just let them blow because you know that you're going to need more and continuous is really the way forward.
00:13:48
Speaker
This is just a temporizing measure.
00:13:50
Speaker
And there's been a lot of studies about the bioavailability of nebulizers versus meter-dosed inhaled albuterol.
00:14:00
Speaker
But I guess in this setting, for delivery continuously and to just make sure that it works, we always go with nebulizers, correct?
00:14:09
Speaker
Yeah, it's a great medical student stump question, right?
00:14:12
Speaker
You know, it's like, you know, what should you give for a person who comes in with an asthma exacerbation, like the non-life-threatening person?
00:14:22
Speaker
And you say, yeah, there's no difference between metered dose inhaler and continuous nebs.
00:14:25
Speaker
But with metered dose inhaler, you're having patient participation, just like you're having with peak flow monitoring.
00:14:31
Speaker
Here, the person's just trying to stay alive.
00:14:33
Speaker
And so now you're going to tell the person, I know you're breathing at a rate of 40 per minute.
00:14:37
Speaker
But I'd like you to squeeze down on the pump and take a nice deep breath in and get the medications.
00:14:43
Speaker
It just doesn't work out that way.
00:14:44
Speaker
So go with NEBS and don't try to be too academic about things.
00:14:48
Speaker
Perfect.
00:14:48
Speaker
What about steroids?
00:14:49
Speaker
I mean, that's also a, the bioavailability is the same PO or IV, but we always start with IV in these sick patients and some of these patients might eventually get intubated.
00:14:58
Speaker
So I think it just makes sense.
00:15:00
Speaker
What is your go-to dose and drug?
00:15:03
Speaker
Does it matter?
00:15:06
Speaker
I mean, again, it's going to be intravenous.
00:15:08
Speaker
You're correct.
00:15:09
Speaker
There's no difference in bioavailability.
00:15:11
Speaker
The mechanism of effect takes four to six hours to work.
00:15:14
Speaker
So why are we in such a rush to get the medications and intravenous?
00:15:17
Speaker
Again, it's just a respiratory distress process.
00:15:20
Speaker
point of view.
00:15:21
Speaker
So, you know, give them the solimedrol, give it intravenously, and then move on to the next step.
00:15:27
Speaker
Because again, that's now in their body.
00:15:29
Speaker
It's going to take hours to work.
00:15:30
Speaker
You got to keep moving on to the next steps and not think that that medication is what's going to save this person in the short term.
00:15:36
Speaker
You mentioned magnesium and you mentioned that there's been a lot of controversy or I would say literature that is inconclusive.
00:15:44
Speaker
But my take and correct me if I'm wrong, Haney, is that probably giving somebody two grams of magnesium IV over 15 to 30 minutes, whatever, when they come into the ED with severe asthma, check that box out and move on, right?
00:16:02
Speaker
Absolutely, absolutely.
00:16:03
Speaker
And I would even give more magnesium.
00:16:06
Speaker
The funny thing I see about magnesium is people are sometimes afraid to give too much magnesium and they're like, I don't know, two grams, their level is normal.
00:16:14
Speaker
I don't want to give any more.
00:16:15
Speaker
Four grams, that's crazy.
00:16:17
Speaker
But then they forget the days when they did their OB rotation and they were taking patients with preeclampsia and those people were on magnesium drips and you're running around hitting people with reflex hammers that hardly ever get hyporeflexic.
00:16:30
Speaker
So my point is, is that magnesium,
00:16:32
Speaker
with normal or even suboptimal renal function, magnesium is extremely well tolerated.
00:16:37
Speaker
And giving them aggressive magnesium dosing may be the thing in conjunction with everything else that helps turn this patient around.
00:16:45
Speaker
Excellent.
00:16:46
Speaker
And obviously, as we are discussing, this is an acute respiratory illness and airway management is going to be very important.
00:16:53
Speaker
So the drugs that we give are straightforward and there's really not a lot.
00:16:59
Speaker
I mean, you and your son, I think a lot of the challenges of managing these patients, Haney, is that we have to make decisions based on clinical information and not necessarily on numbers, right?
00:17:11
Speaker
And that's where you have to be, I think, very, very, very attentive.
00:17:15
Speaker
So let's talk about respiratory support.
00:17:18
Speaker
Is there a role for high flow nasal oxygen?
00:17:22
Speaker
I would say no.
00:17:23
Speaker
The person that we're talking about here should not be getting high flow.
00:17:29
Speaker
To me, it's a waste of time.
00:17:30
Speaker
There's not enough respiratory support to offload those respiratory muscles that are working.
00:17:38
Speaker
Would you use non-invasive and when?
Role of Non-invasive Ventilation and Heliox
00:17:41
Speaker
Yeah, absolutely.
00:17:42
Speaker
And so I'm glad you brought this up because non-invasive should be one of the first things that you put on your patients when they come in.
00:17:48
Speaker
Now, we need to talk about this and take a pause because some people will say, well, wait a minute.
00:17:53
Speaker
Asthma is an expiratory problem.
00:17:56
Speaker
It's not an inspiratory problem.
00:17:58
Speaker
Why would you give somebody non-invasive when they have an expiratory problem?
00:18:02
Speaker
That's just an inspiratory support.
00:18:04
Speaker
And it all goes back to that concept that we started with,
00:18:07
Speaker
We need to support those respiratory muscles because, again, I imagine this imaginary stopwatch that clicks when they hit the door and they're going to fatigue.
00:18:16
Speaker
But if I can unload their respiratory muscles and support their respiratory work, I might be able to push that stopwatch out a little further.
00:18:25
Speaker
I may be able to spread out that time that I have with them so that
00:18:30
Speaker
they have a little bit more time for those medications to kick in, and then maybe they don't go into respiratory failure.
00:18:36
Speaker
So I hope that's clear to everyone who's listening.
00:18:38
Speaker
Again, it's not to support, it's not to fix the expiratory problem.
00:18:42
Speaker
It's just to offload their work of breathing so that you extend that muscle life, if you will.
00:18:49
Speaker
And I think that also something we'll talk about a little bit later, but there's increasing data that pre-oxidination with non-invasive or even high flow when you use it might be a positive for patients that need to be intubated, especially those who need to be intubated very quickly.
00:19:06
Speaker
But we'll get there in a second.
00:19:08
Speaker
But before we get there, I wanted to ask you about Heliox.
00:19:11
Speaker
So Heliox has been around for a long time, back and forth.
00:19:15
Speaker
But what is your take on Heliox, Haney?
00:19:19
Speaker
It's a tough one because we should say for everything we're talking about in life-threatening asthma, there's very limited data because this is a very hard population to study.
00:19:32
Speaker
So with that being said, Heliox has been looked at and the data is kind of meh in there, meaning there is some evidence that says that it might help and there's some evidence that says it makes no difference.
00:19:45
Speaker
Asthma is a small airway disease and
00:19:49
Speaker
in theory heliox should not help it's really a large airway like a trachea main bronchus type of thing where the laminar flow is going to be very helpful to deliver medications and ease work of breathing when you're talking about all the way down at the terminal bronchioles there's so much turbulent flow that heliox is not going to help so i always ask my respiratory therapist
00:20:11
Speaker
you know, is this something that you have quickly available?
00:20:15
Speaker
If they say, I'm the only therapist on, I have to go down to the bowels of the hospital to try and find these tanks and bring it back, I would say I'd much rather have you at the bedside with this patient.
00:20:26
Speaker
If we have lots of resources and the ability to go downstairs and get the tanks, I might bring it up and give it a try for the person.
00:20:32
Speaker
But
00:20:33
Speaker
You know, it's all a resource issue for me.
00:20:36
Speaker
The evidence for me is kind of meh.
00:20:38
Speaker
If I have it available, let's do it.
00:20:39
Speaker
If it's too much work to do it, we have other things that work better with more evidence that we can do for this patient.
00:20:46
Speaker
I think with Heliox also the idea on paper makes a lot of sense, right?
00:20:52
Speaker
So I think that's why it's been around for a long time.
00:20:54
Speaker
But the studies, like you said, have been inconclusive.
00:20:57
Speaker
And that's also part of that is because this is a very hard to study population.
00:21:02
Speaker
So getting any studies that have a significant number of patients is very difficult.
00:21:07
Speaker
The other thing that I want to mention also that sometimes people forget is that heliox, in order to work, has to be 70% helium, 30% oxygen.
00:21:17
Speaker
So you have a very hypoxic patient, which sometimes occurs, you lose the benefit of heliox as you increase the oxygen.
00:21:24
Speaker
So that's just something to keep also in the back of your mind, right?
00:21:28
Speaker
Excellent point.
00:21:28
Speaker
Yeah, if you have somebody who's already desaturating, like let's say this is a pneumonia on top of a severe asthma exacerbation, yeah, you're going to lose your amount of FiO2 to be delivered.
00:21:40
Speaker
So the big question, I guess, is when should you intubate a patient with severe asthma?
Intubation in Asthma: Last Resort Considerations
00:21:48
Speaker
That's a great question.
00:21:50
Speaker
And...
00:21:51
Speaker
It's kind of an evasive answer, but I love this answer.
00:21:54
Speaker
And I got this from an emergency physician named Mel Herbert, who runs a podcast called MRAP, and he's pretty funny.
00:22:03
Speaker
But he says, you should never intubate a severe asthmatic unless you absolutely have to.
00:22:11
Speaker
And it's like, it's a nonsensical, it's almost like a
00:22:19
Speaker
everything that you can not to intubate an asthmatic because as any intensivist knows, the hard work actually starts after intubation with managing these patients.
00:22:27
Speaker
But to say that you should never intubate an asthmatic patient would be a fallacy.
00:22:31
Speaker
So we have to be able to look at the patient and have some objective evidence that the patient is now starting to dip down, that's starting to take a turn and
00:22:41
Speaker
And once they take that turn and you've done all the things we've talked about, which are maximal therapy, you have to be able to look at yourself in the mirror and say, look, I did everything.
00:22:50
Speaker
I had noninvasive on early.
00:22:52
Speaker
I went aggressive with the epinephrine.
00:22:53
Speaker
They're getting continuous nebulizations.
00:22:55
Speaker
They're getting steroids.
00:22:55
Speaker
They're getting magnesium.
00:22:56
Speaker
Heck, I even put heliox on them.
00:22:58
Speaker
And this person's starting to fail.
00:23:01
Speaker
This person is telling me that it's time to intubate.
00:23:04
Speaker
Because if you wait too long and you maintain the hope that something's just going to kick in,
00:23:09
Speaker
then you're going to wait too long, and now you're dealing with the crashing asthmatic airway, which is an airway you definitely don't want to be involved in.
00:23:16
Speaker
That really is a perfect Zen Kwan, right?
00:23:20
Speaker
You should never intubate an asthmatic patient unless you absolutely need to, and I love it.
00:23:25
Speaker
But I think it is very important, right, because we have both, I mean, probably heard of cases where patients get intubated,
00:23:34
Speaker
they go into cardiac arrest and they die and these are young patients and that's not very frequent but it's a very dramatic case that for those who have seen this probably is always something that they will remember afterwards so let's talk a little bit about once you decide it and and one of the things that that i find interesting is that we love abgs right abgs and asthma and
00:23:59
Speaker
I mean, I'll go on the record as saying that there is never a reason to get an ABG in an asthmatic patient.
00:24:06
Speaker
In fact, if you're sitting there poking somebody in an artery while they're struggling to breathe, you're a bad human being.
00:24:12
Speaker
Because there's nothing to gain by getting an ABG on a severe asthmatic.
00:24:17
Speaker
The oxygenation, you can look up at the monitor and see what the pulse ox is.
00:24:22
Speaker
You can, if you, the PCO2, it's irrelevant.
00:24:26
Speaker
It's all clinical.
00:24:27
Speaker
You're looking at the person.
00:24:28
Speaker
But if you really need to know, which again, you don't need to know, you should do a venous blood gas on your patient.
00:24:33
Speaker
So I'm very adamant about ABGs wasting a lot of time, torturing patients and delaying an ultimate decision.
00:24:40
Speaker
The decision to intubate an asthmatic is 1010% a clinical diagnosis.
00:24:46
Speaker
And what are some of the telltales that you should pay attention to?
00:24:50
Speaker
So you talked about some of them at the beginning, but I think also changes, right?
00:24:54
Speaker
So if the pattern of speech is changing, if the way they talk is changing, right?
00:24:59
Speaker
If their level of consciousness is decreasing even so slightly, those are the things that I think should cut your attention, especially considering that this population in general is going to be a younger population.
00:25:12
Speaker
Any other things that we should pay attention to?
00:25:15
Speaker
No, I mean, I'm glad you came back to it because I wanted to.
00:25:18
Speaker
People are going to say, well, you said don't intimate NASMAC unless I absolutely have to.
00:25:22
Speaker
For the junior faculty or maybe the fellows listening to podcasts, what is that tangible thing that they can look at to know it's time?
00:25:30
Speaker
And you basically nailed it.
00:25:31
Speaker
You have a person who's tachypneic and breathing at 35 breaths per minute, and now they're starting to breathe at 30.
00:25:39
Speaker
you know, like 25 breaths a minute, their SATs start to dip down a little bit.
00:25:44
Speaker
They start to head bob a little bit.
00:25:46
Speaker
You have to kind of rouse them up.
00:25:47
Speaker
Those are signs that you are entering the intubation zone.
00:25:50
Speaker
Those are the signs that you're not turning back from.
00:25:53
Speaker
Typically, when we see COPD patients, we try to increase the tidal volume or the respiratory rate, and we try to turn them around.
00:26:00
Speaker
But these are patients that are not turning.
00:26:02
Speaker
They've already declared themselves, their muscles are fatiguing, and now it's time to take their airway.
00:26:08
Speaker
Let's talk about the intubation procedure, Haney.
00:26:11
Speaker
Once you decided to intubate, obviously one of the things that I've heard you say in talks is that this is not the type of intubation you give off to somebody who's learning, right?
00:26:21
Speaker
So absolutely, first and foremost, the most experienced person in the room takes control of this airway because you've got to get it quickly and you've got to get it the first time.
00:26:31
Speaker
How do you think about your pre-oxygenation and positioning and ET tube size?
00:26:38
Speaker
Well, going back to your first point, anytime I have a patient come in with life-threatening asthma, I know that the resident on the shift or the fellow with me is going to hate me by the end of the shift.
00:26:49
Speaker
Because if I take the airway and I'm the most senior person in the room, there's no way they're touching that airway.
00:26:55
Speaker
And every second counts once you push paralytics, which you should for these patients, because they're going to desaturate rapidly.
00:27:03
Speaker
They may develop a respiratory acidosis very quickly because they've been blowing off all that CO2.
00:27:08
Speaker
So it's got to be the fastest person in the room.
00:27:11
Speaker
And if there's an anesthesiologist that happens to be walking by and I know that they're better than me, even though I'm a very proud person, I will hand off that airway to them because this is really first-pass success.
00:27:22
Speaker
We'll talk about that maybe a little bit down the road, but I had to address that.
00:27:26
Speaker
It is so vitally important.
00:27:27
Speaker
This is not a teaching tube.
00:27:29
Speaker
This is the time when you put your big attending pants on and you go in there and you do the intubation.
00:27:37
Speaker
When it comes to pre-oxygenation, I think you've been doing that all along.
00:27:41
Speaker
You've done non-invasive early.
00:27:42
Speaker
You're going to go to 100% if you start to get the sense that you're going to intubate them.
00:27:47
Speaker
So perhaps their FiO2 is like 40 or 50 or 60.
00:27:50
Speaker
Now you crank it up to 100% and make sure you get full denitrogenation of the alveoli.
00:27:56
Speaker
Positioning for the person is something that I'm actually going to wait for until after the paralytics are pushed.
00:28:02
Speaker
So I will keep the person bolt upright at 90 degrees.
00:28:06
Speaker
And if it's time to intubate once the paralytics are pushed, I might intubate this person actually semi recumbent at a 45 degree angle, getting up on a stool and then doing it from above.
00:28:17
Speaker
And then the tools that we're going to use are also important because I'm a big video fan.
00:28:22
Speaker
And this is a situation where you're either going to use your hyperangulated or your standard geometry video laryngoscopy, having multiple tubes available to you, you know, your eight for a male, seven, five for a female, but also having smaller tubes.
00:28:36
Speaker
Because if you see, if you get a look at the airway, you've got to get the tube in.
00:28:40
Speaker
And so have multiple sizes right in front of you ready to go.
00:28:45
Speaker
In terms of tube size, also obviously aim for the bigger tube that you can put in, right?
00:28:50
Speaker
Because these patients might, first of all, have airway resistance and bronchoconstriction, but also might need bronchoscopies down the road for lavages.
00:28:58
Speaker
Excellent point.
00:28:59
Speaker
Yep, absolutely.
00:29:00
Speaker
Always go for the biggest one in the asthmatics for all the reasons that you said.
00:29:04
Speaker
You're going to have a lot of airway pressures on the vents, so try to minimize the amount of resistance that's contributing to the airway pressures.
00:29:10
Speaker
And you mentioned paralytics, so let's talk about drugs now.
00:29:13
Speaker
So this is obviously an RSP situation.
00:29:17
Speaker
What would you do?
00:29:19
Speaker
The thing that I should have mentioned a little earlier on is ketamine...
00:29:24
Speaker
should be part of your initial medical management.
00:29:26
Speaker
So let's just go back in time a little bit when we were talking about the NEBS, the steroids, the magnesium, we talked about epinephrine.
00:29:33
Speaker
Ketamine in sub-dissociative doses can be actually very, very helpful for two reasons.
00:29:39
Speaker
First of all, ketamine is a bronchodilator.
00:29:42
Speaker
It doesn't get enough respect as a bronchodilator.
00:29:44
Speaker
So giving it is another type of muscle relaxant that can cause bronchodilation.
00:29:51
Speaker
But the second thing
00:29:53
Speaker
The second reason why ketamine can be so important is when these patients come in, they feel as though they're going to die.
00:30:01
Speaker
And so there's a fair bit of anxiety that comes with their respiratory distress, and that's making their tachypnea worse.
00:30:11
Speaker
And with tachypnea, we have shortened expiration times, right?
00:30:14
Speaker
That's just the natural phase of things.
00:30:15
Speaker
The faster the respiratory rate, the shorter the expiration time.
00:30:18
Speaker
And asthma is a disease of expiration.
00:30:21
Speaker
So giving ketamine really has a two-pronged effect.
00:30:25
Speaker
The first is bronchodilates them.
00:30:26
Speaker
And the second, it just takes that edge off the patient.
00:30:29
Speaker
So they breathe a little slower, maybe afflowing those respiratory muscles.
00:30:33
Speaker
Now, I'm not saying that you want to give
00:30:37
Speaker
patient any sedative that comes in.
00:30:39
Speaker
I've seen people give Ativan or even the fentanyl just to take away that respiratory edge.
00:30:43
Speaker
The nice thing about ketamine is it doesn't suppress respiratory drive.
00:30:47
Speaker
But let me get back to your question in hand.
00:30:48
Speaker
What medications are we using?
00:30:50
Speaker
I would induce this person for the intubation using ketamine in our dissociative doses now, not the sub dissociative dose we talked about before, in our dissociative doses.
00:31:00
Speaker
And then I would use
00:31:01
Speaker
full dose paralytic, I'd use rock your own for this person because I want this person to be completely relaxed when we go to intubate them.
00:31:09
Speaker
So I'm going to push those medications, I'm going to wait 45 seconds, and then I'm going to lay that patient back just a little bit, get on my stool and try to intubate them with the head of the bed elevated.
Post-intubation Management and Emergency Protocols
00:31:21
Speaker
Excellent.
00:31:22
Speaker
What are some pitfalls to avoid during that process, or immediately after we intubate them?
00:31:30
Speaker
The first thing is, and this goes for any intubation that you do, whether it's an asthmatic, a septic patient, head bleed, whatever, is not calling for your post-tubation.
00:31:40
Speaker
intubation meds to be in the room.
00:31:42
Speaker
So as I'm asking the nurse to go pull meds, the meds I ask for are my induction meds.
00:31:48
Speaker
I'm asking for my paralytics.
00:31:50
Speaker
I'm also asking for vasopressor to be at the bedside because you never know when that person is going to develop post-intubation hypotension.
00:31:56
Speaker
But I'm also asking for my post-intubation medications.
00:31:59
Speaker
I'm asking for my analgesia.
00:32:01
Speaker
I'm asking for propofol, another great bronchodilator, by the way.
00:32:05
Speaker
And I have them in the room.
00:32:06
Speaker
And that's another pitfall because then you have the person who you just intubated
00:32:10
Speaker
And sure, they're paralyzed, they'll be easy to ventilate, but we don't have our sedatives on board.
00:32:14
Speaker
And there's an awareness that comes with that.
00:32:15
Speaker
But there's also the fact that you're not getting another bronchodilator on board.
00:32:20
Speaker
Other pitfalls with intubation, again, I would say is the continued, you know, the continued attempts at intubation.
00:32:27
Speaker
So let's say the most senior person goes to intubate, and they don't get the airway in, there's this
00:32:35
Speaker
reluctance to go for a surgical airway after a few attempts.
00:32:39
Speaker
People will keep trying to get the airway, trying to get the airway.
00:32:42
Speaker
And what's different with this patient versus other patients is that they're not easy to bag.
00:32:46
Speaker
There's a lot of airway resistance.
00:32:48
Speaker
These patients can be extremely difficult to bag.
00:32:51
Speaker
So you're going to have to get a very good seal on that person in between your intubation attempts.
00:32:56
Speaker
And you're going to have to use a little bit more force to bag the
00:33:03
Speaker
bag in, like you see some people do during the code, you're still going to just squeeze a little bit of volume in, but you have to use a lot more force than you normally would to overcome the airway resistance.
00:33:16
Speaker
And those are some of the things I'm sure there's others we can talk about, but those are the things that come to mind with that question.
00:33:22
Speaker
And you mentioned bagging, right?
00:33:23
Speaker
So one of the things that I've noticed, and I want to your take, Haney, is that once they're intubated, adrenaline's high, everybody's excited.
00:33:33
Speaker
I've seen people bag very quickly and very forcefully.
00:33:37
Speaker
And that's also going to, I think, lead us into when we talk about mechanical ventilation, what should be the approach here?
00:33:43
Speaker
Can you maybe give our RT listeners a couple of tips there?
00:33:47
Speaker
Yeah, I mean, honestly, RT, but even physicians.
00:33:50
Speaker
And sometimes physicians are the worst offenders because you get the tube in, you're so proud of yourself that you got this difficult tube, everyone's sweating, you're sweating, and you're just the excitement sets in, you're just bag, bag, bag, bagging.
00:34:03
Speaker
And as we said before, asthma is a disease of expiration.
00:34:08
Speaker
And so you have to slow down that respiratory rate.
00:34:11
Speaker
And you have no feedback yet.
00:34:12
Speaker
When you get on the ventilator, we're going to talk about ways that you can
00:34:16
Speaker
see how much flow there is in the expiratory limb.
00:34:19
Speaker
But now you just have to go with kind of going down to like eight to 10 breaths per minute, being very deliberate about counting those Mississippis and getting that person to bag slow.
00:34:29
Speaker
And, you know, when I'm the person supervising,
00:34:32
Speaker
Those are the things I'm watching after intubation.
00:34:35
Speaker
I'm watching the person bagging like a hawk because that can actually lead to air trapping and barotrauma.
00:34:41
Speaker
And that not only can lead to some worsened respiratory function, but there's also a hemodynamic problem that we haven't talked about yet with severe asthmatics.
00:34:51
Speaker
And you puff up that chest, they can actually drop their pressure on you.
00:34:54
Speaker
And that just comes from dynamic hyperinflation, essentially a compartment syndrome of your chest.
00:35:00
Speaker
And I've heard you talk about this.
00:35:03
Speaker
This might be a good place to discuss it.
00:35:07
Speaker
Let's say that you're intubated somebody in the immediate post-intubation period, or even if somebody is on the vent and they have a cardiac arrest.
00:35:17
Speaker
What do you do first?
00:35:19
Speaker
The very first thing you should do in the person who has asthma, who went into cardiac arrest, or even a severe COPD patient, you have to think about the likelihood.
00:35:28
Speaker
Do you think this person now had a coronary lesion that led them to have ischemia to their heart?
00:35:33
Speaker
No.
00:35:34
Speaker
The likely explanation is that they've had decreased venous filling back to the heart, and this needs to be decompressed.
00:35:41
Speaker
And so the very first thing you should do is think
00:35:43
Speaker
about disconnecting the person from the endotracheal tube and pushing down on their chest to decompress that chest.
00:35:51
Speaker
Now, I want to be very clear about that because people think decompress the chest and that means doing a needle thoracostomy.
00:35:56
Speaker
It doesn't mean that.
00:35:57
Speaker
It means just getting the air out of those dynamically hyperinflated lungs, get them back to a normal volume.
00:36:03
Speaker
And I've seen in a couple cases, people get return of spontaneous circulation with just that maneuver.
00:36:09
Speaker
Now,
00:36:10
Speaker
the patient is also at severely high risk for developing a pneumothorax in those situations.
00:36:16
Speaker
So after you get the person reconnected and you're bagging the person, my advice is still to bring the ultrasound machine over and make sure that there's no pneumothorax because that is a real possibility for these patients that we're talking about.
00:36:29
Speaker
But the first thing I would exclude, the easiest thing to exclude, is just decompressing that chest by pushing gently bilaterally on their anterior chest.
00:36:38
Speaker
Let's move on to mechanical ventilation.
00:36:40
Speaker
So let's say that you decided that you had to intubate.
00:36:43
Speaker
You took all the precautions that you mentioned, Haney, got the tube in, things are moving forward.
00:36:49
Speaker
You also mentioned that you like to sedate these patients.
00:36:51
Speaker
So analgesia, propofol is a great drug to sedate these patients or even ketamine drips.
00:36:58
Speaker
And here, I guess the goal is not to have them interacting with us, but to go deep, right?
00:37:04
Speaker
Go deep.
00:37:05
Speaker
Yep.
00:37:05
Speaker
So you put the appropriate sedation, and now you have him on a ventilator.
00:37:10
Speaker
Let's talk about mechanical ventilation and the severe asthma.
00:37:13
Speaker
What are some general goals or some general thoughts of how you would do it?
00:37:17
Speaker
And what might be some, just to give people a point of reference, Haney's usual starting point?
00:37:25
Speaker
I, because I'm not leaving this person's bedside anytime soon, the respiratory therapist is going to ask me for some generic settings.
00:37:32
Speaker
And I'll say, you know, give me a respiratory rate of 10.
00:37:35
Speaker
I want to get six cc's per kg.
00:37:38
Speaker
And I'm usually going to go for a volume mode just for the simple reason that I don't want there to be any like pressure cutoffs, you know, with, with, um, with the ventilation, but, you know, certainly you can use peak pressures if you want to.
00:37:50
Speaker
But what I'm trying to do here is I'm trying to stretch out the expiratory limb as far as I can.
00:37:55
Speaker
That's the first tenant of managing these patients.
00:37:58
Speaker
I also want the ability to decrease my eye time, which means I want to crank up my flow rate.
00:38:03
Speaker
I want the ability to get whatever tidal volume I'm in.
00:38:06
Speaker
I want to get over a shorter period of time because less time and inspiration is going to add to the amount of expiration that we have.
00:38:13
Speaker
And then I'm going to go with a lower tidal volume.
00:38:15
Speaker
As I said, six cc per kg, sometimes lower because the less air that I put
00:38:20
Speaker
in, the easier it is to get out.
00:38:22
Speaker
So that's my general cookbook answer.
00:38:25
Speaker
But then after those settings are on the ventilator, I'm turning my attention to the vent and I'm watching the flow scalars.
00:38:33
Speaker
And what I want to see is I want to see that expiratory limb, that flow come all the way up to baseline before the next inflection point.
00:38:41
Speaker
Because if we're breathing too early,
00:38:43
Speaker
or we're triggering the vent too early, we're adding to that dynamic hyperinflation and that air trapping, and we need more work to do.
00:38:50
Speaker
And sometimes I'll just dial down my respiratory rate while watching that expiratory limb until it gets as close as it can back to that zero flow baseline before the next breath is delivered.
00:39:00
Speaker
And I'll pause there and just make sure that I delivered that clearly.
00:39:05
Speaker
I think this is an important concept, right, of dynamic hyperinflation.
00:39:09
Speaker
Before we dive into that a little bit more, and you did explain it very clearly, Haney, what's your philosophy on PEEP?
00:39:17
Speaker
And this is obviously tied into dynamic hyperinflation, but it's very different than what we do in ARDS.
00:39:22
Speaker
I just want to see, I mean, what your thoughts are.
00:39:25
Speaker
Yeah, this is something I've kind of bounced around with, you know, for the for the past couple of years.
00:39:31
Speaker
I think I think peep is important, but it's not something that we're going to be relying on for this person.
00:39:38
Speaker
So we don't have to go and drive up the peep for this person who is deeply, deeply sedated, because we don't have to worry about this person.
00:39:46
Speaker
You know, initiating a breath as we would if this person was more awake and we're talking about the concept of, you know, intrinsic PPR for this person.
00:39:54
Speaker
And that's a concept that we could talk about later in the podcast or maybe a different time.
00:40:00
Speaker
But in this case, I'm not going crazy with the people.
00:40:02
Speaker
I'm just going with a standard five of people for lack of a better number.
00:40:08
Speaker
I'm actually interested to hear what your thoughts are, because I've talked to a lot of people about this and the concept of PEEP.
00:40:14
Speaker
Are you splinting open the terminal airways by giving PEEP?
00:40:20
Speaker
I don't think so.
00:40:20
Speaker
I think the person is splinting.
00:40:23
Speaker
them open on their own because of the dynamic hyperinflation.
00:40:27
Speaker
But I'd love your thoughts on that.
00:40:28
Speaker
No, for sure.
00:40:28
Speaker
And I think that, like you said, I mean, the concern here is that dynamic hyperinflation.
00:40:35
Speaker
And I would say that where I fall, and this is not based on
00:40:40
Speaker
Randomized trials, but after speaking a lot of experts and also experiences five or below.
00:40:45
Speaker
So I sometimes even gone lower three.
00:40:48
Speaker
But I do think that the concept of looking at your airflow and making sure that we are getting back to baseline.
00:40:55
Speaker
There's no air trapping or what we call auto peep.
00:40:58
Speaker
is extremely important because in many other situations you might set the ventilator and forget about it for a while doing other things but in this situation it can get ugly really quick right especially when you when you first intubated the patient so
00:41:14
Speaker
I really believe that the concept of dynamic hyperinflation and understanding how to look at your waveforms to make sure that you are delivering the best possible type of breath is important.
Protective Lung Strategies and ECMO Consideration
00:41:28
Speaker
And you emphasize already, Haney, and we'll review for our audience, these patients need deep sedation, sometimes neuromuscular blockers,
00:41:37
Speaker
They need low respiratory rates.
00:41:40
Speaker
They need low tidal volumes.
00:41:43
Speaker
They need an I to E ratio of one to four, right?
00:41:46
Speaker
More if you can, which means that you're going to have a very high flow rate.
00:41:53
Speaker
And you need to make sure that all that is working out.
00:41:56
Speaker
One of the consequences of doing this is that you might have a low minute ventilation that might lead to hypercapnia.
00:42:05
Speaker
But I guess that we all agree that that is something that you will gladly accept if you can protect the airway other ways.
00:42:13
Speaker
Yeah, I got to bring this up because one of the residents came up to me recently and they were at another hospital and they were pretty upset that they had a patient just like we're talking about here.
00:42:25
Speaker
And the respiratory therapist was fighting them because the pH for that patient was like 7.2.
00:42:32
Speaker
And they were doing everything that we had talked about here and they were trying to ensure that the patient was ventilating, but the respiratory therapist was upset that the pH wasn't closer to 7.4 and was fighting the resident on this.
00:42:45
Speaker
And the resident,
00:42:46
Speaker
Their initial reaction was like, I'm doing something wrong.
00:42:48
Speaker
This therapist knows something that I don't know.
00:42:50
Speaker
But we have to be very deliberate about saying, I don't care about the pH if it's greater than 7.2 or maybe even a little lower.
00:43:00
Speaker
We can talk about that gray zone there.
00:43:02
Speaker
But what I really want to do is I'm ensuring that the patient's getting ventilated.
00:43:05
Speaker
That is the thing I care about the most.
00:43:07
Speaker
So education is really important if you get a junior respiratory therapist who's like, I don't know, why is this so acidotic?
00:43:14
Speaker
Why are we going there?
00:43:15
Speaker
Well, that's the reason why.
00:43:16
Speaker
We're getting a little bit of acidosis to benefit the fact that we can ventilate and keep this person alive.
00:43:22
Speaker
And one more thing that we should point out with your respiratory settings that we didn't say deliberately is that
00:43:29
Speaker
You may have the therapist come back, especially a junior therapist who hasn't seen many of these cases coming back and saying, you know, our peak pressures are alarming.
00:43:36
Speaker
You know, what do you want me to do for the settings?
00:43:38
Speaker
And typically what I'll say is like, I want you to increase that peak pressure alarm because we're going to expect that.
00:43:44
Speaker
high peak airway pressures because of the intense resistance that's present in those airways.
00:43:49
Speaker
And you may have to increase the airway pressure alarm to 100 or even 120.
00:43:53
Speaker
And you have to be careful here.
00:43:56
Speaker
You can't just do it and not watch the patient.
00:43:58
Speaker
You're going to have to go back and slowly look for pneumothoraces.
00:44:01
Speaker
But sometimes that's what it takes for the machine to be able to deliver that breath.
00:44:06
Speaker
But if it hits that peak pressure alarm at the standard setting, you may not get any breaths at all.
00:44:11
Speaker
And I think it's a fair reminder for our listeners, a review, that when you look at these pressure alarms, right, when the peaks are going up, but the plateaus are not, you're usually thinking of airway resistance on an asthmatic patient.
00:44:26
Speaker
That is expected, and it can also be used to gauge progress.
00:44:31
Speaker
You would hope to see over time as you're treating these patients that that peak airway pressure goes down, right?
00:44:38
Speaker
The second thing that you mentioned also, which is a high risk for these patients, is bowel trauma and pneumothorax.
00:44:44
Speaker
So if all of a sudden you have increasing the plateau pressures, right, at both the peak and the plateau, you should be thinking of pneumothorax.
00:44:51
Speaker
You should be thinking what else is going on.
00:44:54
Speaker
And I think that should prompt some further investigations for sure.
00:44:58
Speaker
Yeah, well said.
00:44:58
Speaker
Well said.
00:45:00
Speaker
So let's talk about the refractory life-threatening asthma when you've done all the things we mentioned, Haney, and you're still going down in the wrong direction.
00:45:10
Speaker
Is there a role for ECMO, for extracorporeal CO2 removal?
00:45:15
Speaker
What does the literature say about that right now?
00:45:19
Speaker
Yeah, you know, we'll talk about ECMO now, but I do want to also mention inhaled anesthetics, which can be helpful.
00:45:27
Speaker
And I've actually had one patient in my career who I've had to take to the operating room to deliver inhaled anesthetics just for the fact that we couldn't ventilate the patient.
00:45:37
Speaker
anesthesia was very upset and they'll never be happy to take a person to the OR just to administer inhaled anesthetic, but that can be the game changer.
00:45:45
Speaker
And in that particular case I told you about, that can break.
00:45:48
Speaker
Now, there are some devices that are coming on market that will actually allow us to deliver inhaled anesthetics in the ICU through our traditional ventilators, and those are coming.
00:45:58
Speaker
But let me go back to the
00:46:00
Speaker
question that you asked, you know, there's two types of mechanical support that are known.
00:46:06
Speaker
The first is extracorporeal CO2 removal, which arguably this is the reason why this person got intubated because they can't keep up with their CO2 cleaners.
00:46:15
Speaker
Oxygenation is just fine.
00:46:18
Speaker
And those devices aren't available in the States yet, but are in Europe.
00:46:22
Speaker
And the literature that I've read with them have been very, very good in terms of putting a essentially 14 fringe catheter, essentially just a dialysis catheter, and just clearing out CO2, just scrubbing CO2 off while they're getting oxygenated.
00:46:37
Speaker
But if you don't have that available, then using ECMO, VV ECMO, Venovenous ECMO is the way to go.
00:46:43
Speaker
And we've had quite a few patients who have been at our hospital who've done very, very well for their severe asthma just by getting ECMO.
00:46:52
Speaker
So clearly, obviously, the literature is still looking at this.
00:46:55
Speaker
And like you said, we don't have any randomized trials of putting severe asthma who's about to die on ECMO versus not ECMO.
00:47:02
Speaker
But when you look at some of the registries, right, the survival in these patients with asthma on ECMO is going to be higher than ARDS just because of the nature of the patient, right?
00:47:14
Speaker
They're usually healthier.
00:47:16
Speaker
But it might be an option for those who have access to ECMO and just something to think about.
00:47:21
Speaker
And I did want to go back to the inhaled anesthetics, but you did mention this.
00:47:25
Speaker
And just to remind our audience, the reason why you can't do it in most ICUs right now is because you need a gas scavenger system to get rid of inhaled anesthetic gas, right?
00:47:38
Speaker
So that's what they have in the OR.
00:47:40
Speaker
But like you mentioned, for a young person who you think is really going to die, it might be worth trying in an OR and to pay attention because we might have devices that will allow us to deliver these in the ICU in the near future.
00:47:55
Speaker
But like you said, this would be like really a last resort kind of salvage therapy.
00:48:00
Speaker
But because of the properties that these inhaled anesthetics have of bronchodilation, they have been described in case reports as being something that can save somebody's life.
00:48:10
Speaker
Yeah, I mean, I'd make the phone call to anesthesia as I'm calling the ECMO team or the referring hospital, right?
00:48:19
Speaker
I wouldn't make the call to ECMO without at least giving that a try.
00:48:23
Speaker
And luckily, I work in a center that has all of that here.
00:48:26
Speaker
But imagine you're somewhere in the community where you don't have access to ECMO.
00:48:30
Speaker
Like, how are you going to get that person to the center?
00:48:33
Speaker
And sometimes getting to the OR for that treatment might not only temporize and get them better, but it might even reverse the disease altogether and avoid transport.
00:48:41
Speaker
So I think it's an important consideration to at least try.
00:48:44
Speaker
I can't say all your anesthesiologists will say yes or be happy about it, but it's definitely worth a try.
00:48:49
Speaker
Excellent.
00:48:50
Speaker
Any additional considerations that you want to include before we close, Haney?
00:48:55
Speaker
We've had an excellent discussion of a very dramatic presentation that fortunately for most intensive is not something we see every day.
00:49:02
Speaker
But when we do see it, I think using the right clinical judgment can really make a big difference.
Summary and Importance of Rapid Intervention
00:49:09
Speaker
The things that I would say are, and these are just based on some of the pitfalls that I've seen in my own cases or just managing other cases, is the first is you have to be aggressive early on.
00:49:23
Speaker
If that person's coming in speaking one to two phrases to you, this is not one where you say, hey, let's just give them a couple of nebs and see how they turn around.
00:49:31
Speaker
You need to be parked at that patient's bedside, be aggressive, get the non-invasive on early, use epinephrine or some, you know, parenteral beta agonist on board early.
00:49:42
Speaker
You need to identify when this person is starting to fail on you and intubate them before they become a crash intubation.
00:49:50
Speaker
And
00:49:51
Speaker
Remember, intubation is a very high-risk procedure, but if you are experienced and you use the right drugs, then you should be able to get through.
00:49:59
Speaker
And then don't forget about after intubation.
00:50:02
Speaker
That's when the real work starts.
00:50:04
Speaker
That's when managing the ventilator, being aggressive about permissive hypercapnia, watching those expiratory flows...
00:50:13
Speaker
If you do all that stuff and you're aggressive, hopefully your patient will do just fine.
00:50:17
Speaker
But those are the things I see commonly missed because we think about asthma as being something that should just respond to our typical therapy.
00:50:25
Speaker
But this is not a typical disease.
00:50:27
Speaker
This is a pulmonary disease.
00:50:30
Speaker
but it's also a hemodynamic disease.
00:50:32
Speaker
That dynamic hyperinflation can cause some severe hypotension shock and, as you've even said, cardiac arrest.
00:50:39
Speaker
So act early, act aggressively.
00:50:41
Speaker
And then also get your consultants involved.
00:50:45
Speaker
Get anesthesia involved.
00:50:46
Speaker
If you think you're going to wind up doing a surgical airway, we didn't talk about surgical airway, but if you think this is going to be a high-risk airway, then get a surgeon to the bedside to be ready to correct the person during your intubation.
00:50:57
Speaker
But I've said too much,
00:50:59
Speaker
Hopefully that was a good synopsis of everything.
00:51:01
Speaker
And hopefully you have the tools now and your listeners have the tools to take care of the next severe asthmatic that comes through those doors.
00:51:08
Speaker
Absolutely.
00:51:09
Speaker
But you've been on the podcast before, so you know you're not off the hook yet.
00:51:13
Speaker
So I would like to close with a couple of questions that are unrelated to the clinical topic.
00:51:18
Speaker
Would that be okay?
00:51:20
Speaker
Absolutely.
00:51:21
Speaker
So the first question relates to books.
00:51:23
Speaker
Is there any book that has influenced you significantly or that really has impacted you lately or a book that you have gifted often to other people?
00:51:32
Speaker
I think I've mentioned this book before, but it's a book in a TV show, if that's okay.
00:51:38
Speaker
That is perfect.
00:51:41
Speaker
And now that I said it, I'm sure I've said, you know, how to win friends and influence people.
00:51:46
Speaker
And that's a book I read almost once a year or I listen to an audio book once a year.
00:51:52
Speaker
But the reason why I go to it is because we just started, we're almost done with it, but we recently started watching Ted Lasso.
00:52:00
Speaker
And have you seen Ted Lasso?
00:52:02
Speaker
I've seen parts of it.
00:52:04
Speaker
But I read a lot of interesting articles about the leadership lessons from Ted Lasso.
00:52:08
Speaker
So I definitely have to see all of it.
00:52:11
Speaker
Yeah.
00:52:11
Speaker
Oh, my gosh.
00:52:12
Speaker
So the reason why I'm sort of using that show is because I also don't read as much as you do.
00:52:18
Speaker
So I feel kind of embarrassed.
00:52:19
Speaker
So I have to use something else.
00:52:20
Speaker
But Ted Lasso, what's amazing about it is a couple of things.
00:52:24
Speaker
The first thing that's amazing is it's just...
00:52:27
Speaker
It's a guy who knows how to make people feel good.
00:52:31
Speaker
a person who's a great leader, who knows how to use the right words, who hardly ever takes anything personally and makes everyone around him better just by being a good person.
00:52:41
Speaker
And so it touches on a lot of the aspects within how to win friends and influence people.
00:52:46
Speaker
And I think that when you're working in a busy ICU where there's a lot of stress, especially post-pandemic, where people are already going through the stuff every day,
00:52:58
Speaker
Being that type of person that walks on the unit, that's always bubbly, that's always happy, that brings out the best version of people around them is so important.
00:53:07
Speaker
And while it's not really an ICU topic, it's a life topic.
00:53:11
Speaker
I think where we work in the environments we work with the toxicity that we sometimes seeing.
00:53:17
Speaker
Those two things, that book and that TV show are a must watch and a must read.
00:53:22
Speaker
In fact, I'm watching Ted Lasso again now going back and I'm taking notes as I'm watching it because I've incorporated a lot of the things that Ted Lasso has said in what I do every day.
00:53:33
Speaker
So it's a definite recommend.
00:53:35
Speaker
Perfect.
00:53:36
Speaker
And we'll definitely put links in the show notes.
00:53:39
Speaker
The second question is what non-medical YouTube, TikTok, internet, video, or TED Talk should every intensivist watch?
00:53:51
Speaker
You know...
00:53:54
Speaker
I knew you'd ask a question like that.
00:53:56
Speaker
And I don't actually have a great answer for you because I watch so much goofy stuff.
00:54:02
Speaker
What I can say is there's a couple of dad joke things.
00:54:07
Speaker
dad joke kind of TikToks that I watch and come up on my feed.
00:54:12
Speaker
And I like them for two reasons.
00:54:13
Speaker
The first is I just think it's funny.
00:54:15
Speaker
And anytime I can break my day up with some humor and put perspective on things, it's a good thing.
00:54:20
Speaker
But the second thing I've started to do is I've started joking around a lot more with my families and my patients.
00:54:26
Speaker
Now, I don't like to walk into the room and be a goofball.
00:54:28
Speaker
I don't want them thinking that a clown is taking care of them.
00:54:31
Speaker
But I'll sometimes say, do you want to hear a joke?
00:54:34
Speaker
And 9.5 times out of 10, someone's going to say yes.
00:54:37
Speaker
And even though the joke might not get a big bellow laughter, I'll sometimes get a smile and a chuckle and say, hey, thanks for that, doc.
00:54:45
Speaker
I was having a bad day and I appreciate the effort.
00:54:48
Speaker
So I just put a whole bunch of TikToks with dad jokes on them.
00:54:51
Speaker
And it just now makes me happy.
00:54:53
Speaker
And hopefully I'm making some patients and their families a little less sad during their day.
00:54:59
Speaker
Perfect.
00:54:59
Speaker
So I guess this is the perfect segue for me to give you an ICU dad joke.
00:55:06
Speaker
Would you want to hear a good ICU dad joke?
00:55:09
Speaker
Any day.
00:55:11
Speaker
Why is it a bad idea to play hide and seek in the ICU?
00:55:14
Speaker
I don't know.
00:55:16
Speaker
ICU.
00:55:16
Speaker
Okay.
00:55:18
Speaker
Well done.
00:55:30
Speaker
Let's close
Connect with Dr. Malamud and Further Resources
00:55:31
Speaker
there.
00:55:31
Speaker
And you've obviously been a big proponent and very involved with what originally was hashtag foam, free open access medical education, but really promoting education through different channels, right?
00:55:49
Speaker
And I know that this is something that you're very passionate about.
00:55:52
Speaker
So where can our listeners find your content and where can they interact with you?
00:55:58
Speaker
So on social media, I'm at critical care now, all one word, critical care now on YouTube, on Instagram, TikTok, Facebook.
00:56:08
Speaker
But they're all slightly different content that's tailored towards the page that you're on.
00:56:13
Speaker
So that's a place where people can find some of the free open content.
00:56:17
Speaker
I'm staying away from X these days just because it's –
00:56:20
Speaker
It's weird.
00:56:21
Speaker
So you may not find me on much there anymore, but there's, I have a newsletter that I put out that has a ton of my content that we do every single week.
00:56:31
Speaker
It's all free.
00:56:32
Speaker
It's open access.
00:56:33
Speaker
If they're interested in that, they can go to resusx.com and then the upper right hand corner, there's a newsletter that people can sign up for.
00:56:40
Speaker
And then every week you basically just get an email dropped in your, in your box that go seven or eight things that might make your week a little bit more interesting than
00:56:49
Speaker
as you read through.
00:56:51
Speaker
And as I was preparing for the show, there was one more thing that I'd like to offer to your listeners, and maybe we can make this link available.
00:56:58
Speaker
But
00:56:59
Speaker
Because in the spirit of free open access education, I'm going to give everyone access to our conference that we did last year.
00:57:07
Speaker
If they just go ahead and click on the link and they can sign up for that.
00:57:11
Speaker
They get the conference.
00:57:12
Speaker
They get to watch it.
00:57:14
Speaker
Sergio was actually faculty at the conference and has been for the past few years.
00:57:18
Speaker
So you can even see Dr. Zanotti talk a little bit about critical care and leadership.
00:57:22
Speaker
Always great talks for IU, by the way.
00:57:25
Speaker
Hey, Nii, always a pleasure to have you on.
00:57:27
Speaker
Thank you so much.
00:57:27
Speaker
We'll definitely include all those links for our listeners, and I look forward to talking with you again soon.
00:57:34
Speaker
I can't wait.
00:57:34
Speaker
Thanks again for having me today.
00:57:36
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:57:40
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:57:46
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:57:51
Speaker
To learn more, visit www.soundphysicians.com.