DILEMMAS IN DAY-TO-DAY CARE
ASTHMA UNDER CONTROL
Drug not commonly used for asthma proves beneficial
By Jennifer Keefer, BSN, CFRN, NRP, & Ryan Hodnick, DO, NRP, FAWM
Your helicopter is called to rendez- vous with an ALS unit that has a 60-year-old female on board in severe
respiratory distress. On arrival, you find your
patient altered in the back of the ambulance.
She’s hypoxic, with oxygen saturation (SpO2)
in the upper 60s, and has audible wheezing.
She will not keep the non-rebreather mask on.
Initially she was found unresponsive by the ALS crew, who first
attempted intubation, but had difficulty doing so as they don’t carry
paralytics. An 18-gauge IV had been
established in the left antecubital
area, and she received 125 mg of
solumedrol IV. The first arriving
ALS crew has treated her before
and indicates she has a history of
severe asthma and has been intubated before in the past.
You have a 25-minute air transport over a mountain range that’s
9,000 feet above sea level to the
nearest hospital with the appropriate level of care available. You and your
partner decide that despite the difficulty in
managing asthma patients on a ventilator, the
patient will need intubation for airway control
and to help further treat her asthma.
Setup for intubation with paralytics is
begun to increase the success of intubation.
The patient continues to be non-cooperative
and combative from her hypoxia.
You plan to give her a sedation dose of ketamine, both to get control of the patient, and
to better pre-oxygenate her prior to the intubation attempt. The setup is for a delayed
sequence intubation (DSI) using ketamine
Plans are going well until the patient, in
her altered state, pulls out her only working
IV before medications can be drawn up and
given. Bleeding from the site occurs and is
quickly controlled. At first this seems like a
major problem for your plan of DSI, however,
The transport ventilator is set up and
attached to the bag-valve mask (BVM), and
you have intermediate focus on holding a good
mask seal and providing controlled ventila-
tion. The patient is supine on the cot and the
head of the bed is raised to 30 degrees. She’s
ramped to the ear-to-sternal notch position to
achieve better oxygenation and intubation con-
ditions. Underneath the mask, a nasal cannula
is placed at 20 Lpm in preparation for apneic
oxygenation once the paralytic is administered
and takes effect.
During this time, another IV is established,
and the patient’s SpO2 climbs into the upper
90s. Equipment is checked and prepared,
including a video laryngoscope, suction and
waveform capnography. Once the patient has
been saturating in the upper 90s for a few minutes, you decide to push the rocuronium and
attempt the intubation.
To give the rocuronium a chance to fully
take effect, a full minute goes by before an intubation attempt is made. The patient continues
to be bagged with good mask seal using the
ventilator with a nasal cannula underneath.
The mask is removed and your partner
inserts the video laryngoscope with ease, finds
the epiglottis and exposes the glottic opening.
The endotracheal tube is delivered without
any desaturation on first attempt. Intubation
is confirmed with positive waveform capnogra-
phy, and the patient is placed on the ventilator.
Keeping in mind that she has an obstruc-
tive lung process, her end-tidal carbon dioxide
(EtCO2) readings will help guide
ventilator management. Her venti-
lator strategy includes monitoring of
peak pressures, waveform capnog-
raphy and a prolonged expiratory
time (a 1: 5 inspiratory-to-expira-
An in-line DuoNeb (albuterol
and ipratropium) and magnesium
are administered for her asthma.
She’s given another bolus dose
of ketamine, this time via IV and
started on a ketamine drip with fen-tanyl for sedation and comfort. The
patient is transported without incident comfortably on the ventilator
for the 25-minute transport.
The patient was delivered to the ED and diagnosed with a severe asthma exacerbation. She
has no evidence of pneumonia or other infection. After being admitted to the ICU she continues similar treatment to that she received
from EMS. She’s extubated within two days
and discharged to home in five days.
Asthma is a very common disease seen in the
field. Roughly 1 in 15 Americans suffer from
this disease. Since 1980, the fatality rate from
asthma has increased significantly. 1 There are
many types of intimidating patients that you
may encounter in the field, with severe asthmatics being one of those. Underlying inflammation causes swollen airways and excess
mucus, which dramatically reduces the size
There are many
types of intimidating
patients that you may
encounter in the field,
with severe asthmatics
being one of those.