Sunday’s "Crashed Status Asthmaticus" session was billed as a sort of “choose your own adventure” journey—during which the participants got to decide how to, as Meredith Greer, MD, said, “break the death spiral of status asthmaticus.”

The session began by defining status asmathicus, a condition in which a patient has severe airway obstruction and asthmatic symptoms that persist despite attempts to mitigate them. It can come on strong and fast—leading the patient to “crash.”

“No single clinical or diagnostic index has been known to predict the clinical outcomes of this condition. A multi-pronged approach, combining clinical evaluation, appropriate diagnostic tests, and rapid symptom relief, can improve outcomes for patients with this condition,” according to StatPearls.

Status Asthmaticus. StatPearls.

During the session, participants discussed assortment of approaches that they could take to save their patient’s life. Try Heliox? Intubate? ECMO? They waved colored cards in the air to signal the choices they’d make.

The goal was to aid in making non-invasive decisions and smart clinical choices in the hypothetical scenario in which their patient was crashing.

Some of the topics discussed in this session included:

• Heliox, which is a mixture of helium and oxygen: As Justin Rearick, RRT-NPS, AE-C, RRT-ACCS, MS, RRT, says, Heliox is often “stored in the “deep dark” underbelly of the hospital. While pediatrics use heliox frequently, “The problem with Heliox is in the evidence—which is contradictory,” he says. “But if you have it, why not use it? It’s safe, well-tolerated, and has multiple means of deployment. It could buy you time.” He says it’s key for clinicians to know what they have available. “When all else fails, you might as well try.”

• Non-invasive positive pressure ventilation (NIPPV): NIPPV s a good option for patients without significant encephalopathy or secretions, as it provides ventilatory support versus tracheal intubation. It’s indicated for tachypnea w/ RR >2-30 bpm, hypoxemia, hypercapnia, use of accessory muscles to breathe, according to session slides. The session hosts say that NIPPV’s success with COPD could potentially be translated to asthma, which is why, its use has been on the rise in the past decade. It helps to correct the cycle of dyspnea leading to anxiety leading to tachypnea leading to obstructive airways and inadequate expiratory time leading to lung hyperinflation leading to diaphragm flattening and difficult inhaling. This is a “vicious cycle,” says Dr. Conroy. 

• Intubation: “After utilizing NIPPV, heliox and other methods…when do you intubate?” Dr. Conroy asked the room. The resounding answer from the room? There’s no one clear answer. “It makes me as tachycardic as the patient is to say, I don't have a singular answer,” she said. The general idea is that intubation should follow based on a few gathering data from the patient’s work of breathing, altered mental state, ongoing VQ  (ventilation-perfusion) mismatch, and impending respiratory failure. 

• Extracorporeal membrane oxygenation (ECMO): “ECMO is used for life-threatening asthma,” usually for young patients who have a lot of life ahead of them, says David Shore, MD.  “It works. It takes the lungs out of the equation. It helps improve things.” Shore says ECMO has a high survival rate, but that it’s also more costly—which shouldn’t matter when it comes to saving a patient’s life. 

• Biologics: “Is there a role for biologics in status asthmaticus?” Conroy says yes, although there haven’t been large studies and it’s generally used in an outpatient setting. 

Prevention: Lastly, prevention is key, Conroy says. “Inhaler access, cost, delivery and adherence, making sure they’re using it correctly…are all things we can do to prevent status asthmaticus,” she says.