Asthmaventilatory management Early period

1. Initially give low VT (5ml/kg) breaths at low rate (5-10/min) to assess degree of bronchospasm and air trapping. Slowly increase VT (to 7-8ml/kg) ± increase rate, taking care to avoid significant air trapping and high inspiratory pressures. Low rates with prolonged I : E ratio (e.g. 1:1) may be advantageous. Avoid very short expiratory times.Do not strive to achieve normocapnia.

2. Administer muscle relaxants for a minimum 2-4h, until severe bronchospasm has abated and gas exchange improved. Although atracurium may cause histamine release, it does not appear clinically to worsen bronchospasm.

3. Sedate with either standard medication or with agents such as ketamine or isoflurane that have bronchodilating properties. Ketamine given alone may cause hallucinations while isoflurane carries a theoretical risk of fluoride toxicity.

4. If significant air trapping remains, consider ventilator disconnection and forced manual chest compressions every 10-15min

5. If severe bronchospasm persists, consider injecting 1-2ml of 1:10,000 epinephrine down endotracheal tube. Repeat at 5min intervals as necessary.

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