Managing asthma with noninvasive ventilation (NIV)
Imagine during your next clinical shift you’re called to evaluate a patient with a history of asthma. She is in severe respiratory distress. Since you recently had good success with using noninvasive ventilation (NIV) in a patient with chronic obstructive pulmonary disease (COPD), you consider using NIV in this patient with asthma.
Asthma is similar to COPD—in both, there is airway obstruction, particularly during expiration. And while the obstruction is somewhat different in its pathology—asthma has inflammation due to an accumulation of mucus and thickening of the bronchial walls whereas COPD has the loss of elasticity to the walls—you wouldn’t be alone to think that the treatment should provide similar beneficial results.
However, there is a lack of literature on the use of NIV in acute asthma exacerbations. A 2011 clinical practice guideline from the Canadian Critical Care Trials Group “make(s) no recommendation about the use of noninvasive positive-pressure ventilation in patients who have an exacerbation of asthma, because of insufficient evidence.” 1
In fact, no studies have demonstrated improved morbidity or mortality rates from the use of NIV in patients with asthma.
For these same reasons, a 2012 Cochrane Review on NIV for acute asthma exacerbations states that “this course of treatment remains controversial.” 2
No large randomized trial has evaluated the use of continuous positive airway pressure (CPAP) in asthma patients. In the literature that exists, the small trials looking at CPAP in asthma concluded there was no harm to its use, but reported no conclusive mortality or intubation benefit. The physiologic benefits of improved airflow and improved deposition of nebulized bronchodilators have not translated into a measurable change in clinical outcomes.
So, despite the lack of support from guidelines and medical literature, I hope I have still convinced you to consider a trial of NIV for your patient in asthma.
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- Keenan, SP, Sinuff, T, Burns, KEA, et al. 2011. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ. 183: E195–E214. PMID: 21324867
- Lim, WJ, Akram, RM, Carson, KV, et al. 2012. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev. 12: CD004360. PMID: 23235608
- Holley, MT, Morrissey TK, Seaberg, DC, et al. 2001. Ethical dilemmas in a randomized trial of asthma treatment: can Bayesian statistical analysis explain the results? Acad Emerg Med. 8: 1128–1135. PMID: 11733289
- Soma, T, Hino, M, Kida, K, et al. 2008. A prospective and randomized study for improvement of acute asthma by non-invasive positive pressure ventilation (NPPV). Intern Med. 47: 493–501. PMID: 18344635
- Soroksky, A, Stav, D, and Shpirer, I. 2003. A pilot prospective, randomized, placebo-controlled trial of bilevel positive airway pressure in acute asthmatic attack. Chest. 123: 1018–1025. PMID: 12684289