The Crashing Asthmatic

17 May

I had prepared this before the 3MG trial came out and hat tip to simon carley and his post for alerting me to it.

UPDATE: have since read the 3MG trial and here’s my thoughts on that

In my current dept, there’s a monthly joint ICU/ED meeting. I recently presented on some of the evidence base and strategies for managing life-threatening asthma. The 15 people there seemed to enjoy it so now i’m sharing it with the rest of the #FOAMed community.



I’ve included some references below from some of the papers cited in the talk.

Two talks in particular deserve mention.

One on EM:RAP by Mel Herbert himself back in 2007 [subscription needed] and the other from EMCrit.

Lim, Wei Jie, Redhuan Mohammed Akram, Kristin V Carson, Satya Mysore, Nadina A Labiszewski, Jadwiga A Wedzicha, Brian H Rowe, and Brian J Smith. “Non-Invasive Positive Pressure Ventilation for Treatment of Respiratory Failure Due to Severe Acute Exacerbations of Asthma..” Cochrane Database of Systematic Reviews (Online) 12 (2012): CD004360. doi:10.1002/14651858.CD004360.pub4.

Mohammed, S, and S Goodacre. “Intravenous and Nebulised Magnesium Sulphate for Acute Asthma: Systematic Review and Meta-Analysis..” Emergency Medicine Journal 24, no. 12 (December 2007): 823–830. doi:10.1136/emj.2007.052050.

Nair, Parameswaran, Stephen J Milan, and Brian H Rowe. “Addition of Intravenous Aminophylline to Inhaled Beta(2)-Agonists in Adults with Acute Asthma..” Cochrane Database of Systematic Reviews (Online) 12 (2012): CD002742. doi:10.1002/14651858.CD002742.pub2.

Rowe, B H, J A Bretzlaff, C Bourdon, G W Bota, and C A Camargo. “Magnesium Sulfate for Treating Exacerbations of Acute Asthma in the Emergency Department..” Cochrane Database of Systematic Reviews (Online) no. 2 (2000): CD001490. doi:10.1002/14651858.CD001490.

Tobin, A. “Intravenous Salbutamol: Too Much of a Good Thing?.” Critical Care and Resuscitation : Journal of the Australasian Academy of Critical Care Medicine 7, no. 2 (June 2005): 119–127.

“British Guideline on the Management of Asthma” (February 2, 2012): 1–151.


I had some correspondence from the author of this paper [free full text] regarding the ‘atrial calming’ effect of magnesium. I certainly gave lots of IV magnesium for patients in fast AF. Usually not for the ‘lone AF’ patients, but the sickies with pneumonias and deranged electrolytes. I’d never considered that the supposed rate control effect of magnesium might be useful in the asthmatic to help control the slightly ridiculous tachycardia you get if you’re doing it right.

As mentioned, the paper is free and well worth a read and a good reference.


13 Replies to “The Crashing Asthmatic

  1. Hi Andy, sorry about 3MG 😉 though they excluded patients with life threatening features. Might Mg have an effect in that group, but not in the severe group? 3MG does not really tell us so the comments on the St.Emlyn’s blog suggests that colleagues would still give it if the patient is truly crashing in front of you.

    Great to see another great blog post.


    • I agree Simon – 3MG does not apply to the crashing asthmatic.
      I have used magnesium for asthma, but never in a patient that was NOT admitted to hospital (one of two primary outcomes in this study – BTW how can a study have TWO primary outcomes…?).

  2. Hi Andy
    Quick Q. Can we be relaxed about high airway pressures in ventilated asthmatics as the high peaks are reflective of high resistance and not transmitted to the alveoli?
    I realise that intrinsic PEEP is a problem, but we can measure this and then accept higher pressures if auto PEEP is low enough?

    • Peaks or plateaus? Was always taught to be careful with the plateau and be less stresses about the peak pressure as the plateau is the one that is reflected in the alveoli? Would need to pull out the textbook and weingart’s lecture to know for sure!

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