Ep 193 The Crashing Asthmatic – Recognition and Management of Life Threatening Asthma

In part 1 of this 2-part podcast series on asthma with Dr. Leeor Sommer and Dr. Sameer Mal we covered asthma mimics, risk stratification, ED treatment and who is safe to go home. We drove home that there are many important details in risk stratifying these patients, making sure they are on the right medications, and good discharge instructions to avoid bounce backs and morbidity. In this part 2, we dig into the recognition and management of the crashing asthmatic. We answer such questions as: what are the key elements in recognition of threatening asthma? What are the most time-sensitive interventions required to break the vicious cycle of asthma? What are the best options for dosing and administering magnesium sulphate, epinephrine, fentanyl and ketamine in the management of the crashing asthmatic? What is the role of NIPPV in the management of life-threatening asthma? What are the factors we should consider when it comes to indications for endotracheal intubation of the crashing asthmatic? What role do blood gases play in the decision to intubate? What are the most appropriate ventilation strategies in the intubated asthma patient? and many more...



Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary and blog post by Sara Brade, edited by Anton Helman April, 2024

Cite this podcast as: Helman, A. Sommer, L. Mal, S. The Crashing Asthmatic - Recognition and Management of Life-threatening Asthma. Emergency Medicine Cases. April, 2024. https://emergencymedicinecases.com/crashing-asthmatic-life-threatening-asthma. Accessed September 14, 2025

Résumés EM Cases 

Go to part 1 of this 2-part podcast on adult asthma exacerbations

Recognition of life-threatening, near fatal asthma



* Appearance: Agitated, obtunded, few word dyspnea, accessory muscle use/ tripoding, respiratory arrest

* Vitals: hypoxic, increased (>30) or decreased RR, elevated HR (>120), bradycardia indicative of impending arrest

* Physical exam: silent chest, biphasic wheeze

* Bedside investigations: Peak flow high 20s) and increased work of breathing

* CPAP or BPAP is preferred over HFNC, and CPAP is preferred over BPAP for patients with especially high respiratory rates who are unable to trigger the BPAP adequately due to the short inspiration phase

* Consider ketamine or fentanyl to facilitate the use of NIPPV

* Endotracheal intubation should be the last resort ventilation strategy

* Intubation is generally required for patients presenting with, or who have progressed to, respiratory arrest/ severely obtunded requiring BVM/ not protecting airway

* If endotracheal intubation is necessary, minimize the apneic period and use an obstructive ventilation strategy to avoid hyperinflation



The following tables include indications for and cautions using CPAP, BPAP, HFNC, endotracheal intubation and ventilation settings.





Rapid Sequence Intubation (RSI) pearls in the crashing asthmatic



* Have an epinephrine infusion ready to run (or push dose epinephrine drawn up) before intubation as hypotension is likely to occur when intubating the crashing asthmatic, as epinephrine is an ideal drug to correct hypotension in this scenario.

* Allow the patient to sit upright for as long as possible during the p...