Asthma exacerbations can be life-threatening, with 25,000 to 50,000 cases a year requiring admission to intensive care in the United States. Appropriate triage of life-threatening asthma is dependent on both static assessment of airway function and dynamic assessment of response to therapy. Treatment strategies focus on achieving effective bronchodilation with inhaled beta2 agonists, muscarinic antagonists, and magnesium sulphate while reducing inflammation with systemic corticosteroids. Correction of hypoxemia and hypercapnia, a key in managing life threatening asthma, occasionally requires the incorporation of non-invasive mechanical ventilation to decrease work of breathing. Endotracheal intubation and mechanical ventilation should not be delayed if clinical improvement is not achieved with the conservative therapies. However, mechanical ventilation in these patients often requires controlled hypoventilation, adequate sedation, and occasional use of muscle relaxation to avoid dynamic hyperinflation which can result in baro- or volu-trauma. Sedation with ketamine or propofol is preferred because of their potential bronchodilation properties. In this review, we outline strategies for the assessment and management of patients presenting with acute life-threatening asthma focusing on those requiring admission to the intensive care unit.
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