A 30s F patient with a history of asthma and >50 intubations was sent to psych for evaluation of SI after being arrested by PD. She is brought back for a sudden, severe asthma attack. On exam, she is in severe respiratory distress. She is tripoding with diffuse stridor, inspiratory, and expiratory wheezes. Her VS are HR 130, RR >30, BP 140 / 70, T 98.0, sat of 97 while receiving a neb. She is unable to talk but she is able to cooperate with questions (e.g. give me your hand so I can put in an IV). You are unable to establish an IV. What do you do next?
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Intubation problem
I’m a big fan of ketamine for asthma, with or without intubation. An induction dose of ketamine (1.0-1.5 mg/kg IV) will make the asthma so much better sometimes that you don’t have to intubate the patient (give ketamine, see-hear-feel the patient loosening up, then hold the bvm over the face [without bagging usually] and wait for patient to wake up). Most older attendings have experienced this because back in the day the only drugs we had for intubation induction were ketamine and thiopental. Despite its downside of producing secretions, it’s a good asthma drug.
When you meet resistance in the airway as you are intubating, it is very important not to force the tube down (kudos to JC for doing the right thing). Excessive force may damage the trachea / airway and require operative repair later on. The narrowest part of the adult airway is typically the glottis, but occasionally it is not the case. The obvious answer is to use a smaller tube, and this usually works. We try to use larger caliber ETtubes in asthma, but if you can’t, you can’t. We used a 6.5 instead of the usual 7.5 and it went in.
The next question is “why?” Why was there resistance? The common answer in that a patient has been intubated before and now has tracheal stenosis or tracheomalacia. These patients usually come with a trach scar. Our patient had no trach scar. I scanned his neck to see if there was something unexpected and we found nothing. The patient had an uneventful icu stay and was extubated two days later.
Should we use ketamine in asthma like we use magnesium in asthma? Maybe. There are not many RCTs, and most of them use lower doses of ketamine. Many studies are in peds and as far as I know, they were all negative studies. My question would be if it’s any better than SQ Epi.