Key messages

• The three basic mechanisms of the disease process of asthma are airway wall inflammation, smooth-muscle-mediated bronchoconstriction, and intraluminal mucus. Therefore therapy must include aggressive utilization of anti-inflammatory medications and bronchodilators.

• Maximal bronchodilator and supportive therapy should be provided under the highest level of observation and monitoring in an intensive care or high-dependency unit.

• Mechanical ventilation is indicated in the asthmatic who continues to deteriorate despite maximal medical therapy.

• The aim of mechanical ventilation is to maintain adequate arterial oxygenation and control acidosis while specific therapeutic measures reverse bronchospasm, reduce bronchial epithelium inflammation, mobilize secretions, and suppress airway hyper-reactivity.

• Deterioration despite optimal treatment, including oral steroids and accelerated use of inhaled b-agonists, identifies patients at higher risk for fatal asthma. A history of near-fatal asthma requiring mechanical ventilation is the greatest single predictor of subsequent asthma death.

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