Severe status asthmaticus: Management with permissive hypercapnia and inhalation anesthesia

Objective: To describe the difficulties that can be encountered during mechanical ventilation of severe status asthmaticus and to discuss the safety of permissive hypercapnia as a ventilatory strategy and the role and limitations of inhalation anesthesia in the treatment of refractory cases. Design: Case series and review of literature. Setting: Intensive care unit of a tertiary care hospital. Patients: Two patients with severe status asthmaticus. Interventions:Administration of inhalational anesthetics. Measurements and Main Results: Both patients had respiratory failure secondary to status asthmaticus requiring mechanical ventilation and permissive hypercapnia. They also received inhalational anesthetics because of refractory bronchoconstriction. Levels of Paco(2) in each case were among the highest and most prolonged elevations (> 150 mm Hg for several hours) reported to date. In one case, life-threatening difficulties with ventilation were encountered related to the use of an anesthesia ventilator. Although they had complications related to the severity of their illnesses, both were treated to recovery. Conclusions: Mechanical ventilation in severe status asthmaticus can be challenging. Permissive hypercapnia is a relatively safe strategy in the ventilatory management of asthma. High levels of hypercapnia and associated severe acidosis are well tolerated in the absence of contraindications (i.e., preexisting intracranial hypertension). Inhalation anesthesia may be useful in the treatment of refractory cases of asthma but should be used carefully because it may be hazardous owing to poor flow capabilities of most anesthesia ventilators.