Invasive Respiratory Support in Critical Pediatric Asthma

In the United States and Canada, severe asthma requiring mechanical ventilation has declined over the past decade reflecting a rise in noninvasive therapies. When aggressive noninvasive therapies fail, endotracheal intubation and mechanical ventilation are lifesaving and should be planned for in advance. As speed is important, the most experienced practitioner should intubate and rapid correction of hypercarbia and respiratory acidosis should be avoided. An elevated minute ventilation may cause pulmonary hyperinflation leading to air-leak syndrome and/or hemodynamic instability. Patients with severe air flow obstruction in asthma typically have near-normal respiratory system compliance. Therefore, an increase in plateau pressure (P_plat) usually reflects dynamic hyperinflation. A suggested upper limit for P_plat is 25-30 cm H₂O. Intrinsic PEEP (PEEPi) is measured with an expiratory hold and is valuable in that PEEP set on the ventilator can be lower than PEEPi. A reasonable ventilation strategy involving low ventilator rates and PEEP without quick correction of blood gases should be adopted. Alternative modalities to conventional mechanical ventilation are limited and unless very experienced with high-frequency oscillatory ventilation, the risk likely outweighs benefit. Heliox may be beneficial but cannot be delivered by every ventilator and this varies by manufacturer. Inhaled anesthetics are direct bronchodilators and likely beneficial but as no conventional ICU ventilator can deliver them, close cooperation with Anesthesiology is needed. Extracorporeal membrane oxygenation (ECMO) is a rescue therapy that is particularly useful in cases of severe air-leak syndrome. As with mechanical ventilation, ECMO does not reverse the asthma disease process but allows support of the patient until there is improvement with other therapies. Most children who die experience cardiac arrest prior to hospitalization. Otherwise, most mechanically ventilated children survive to hospital discharge but there is a suggestion of additional mortality from asthma in the following decade.