Managing asthma with noninvasive ventilation

In this video, we'll look at the evidence for (and against) the use of NIV in patients with acute asthma exacerbations and consider when NIV might be useful in this cohort.

Michael Allison, MD
Michael Allison, MD
28th Apr 2020 • 3m read

The use of noninvasive ventilation (NIV) for treating asthma is controversial. In this video, from our Noninvasive Ventilation Masterclass, we'll look at the evidence for (and against) the use of NIV in patients with acute asthma exacerbations and consider when NIV might be a useful therapy for this cohort.

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Noninvasive ventilation (NIV) is a powerful therapy that clinicians can add to their ventilation toolboxes. This course will cover the indications for NIV, initiation and optimization, how to monitor patients on NIV, and how to wean them from it. We’ll delve into the controversial uses of NIV, when NIV is a first-line therapy, and how to rationally test its effectiveness in these situations.

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Video transcript

Imagine on your next clinical shift, you're called to evaluate a patient with a history of asthma. She's in severe respiratory distress. Since you recently had good success with using an IV in a patient with COPD, you consider using non invasive ventilation, this patient with asthma. But as you do that, you're wondering, can I successfully apply non invasive ventilation to patients with asthma?

You think you can because asthma has a lot of similarities to COPD. You've got airway obstruction, particular during expiration, as a hallmark of both. And while the obstruction is somewhat different as pathology, you're wondering if the clinical benefit with non invasive ventilation would work on both. In asthma, you've got inflammation due to an accumulation of mucus and thickening of the bronchial walls.

In COPD, you have the loss of elasticity of the walls. So you wouldn't be far off by thinking that non invasive ventilation should provide similarly beneficial results. However, there's a dearth of literature on the use of non invasive ventilation and acute exacerbations of asthma. A 2011 clinical practice guideline from the Canadian critical care trials group makes no recommendation about the use of non invasive positive pressure ventilation in patients who have an exacerbation of asthma because of insufficient evidence.

In fact, no studies have demonstrated improved morbidity or mortality rates from the use of non invasive ventilation in patients with asthma. For these same reasons, a 2012 Cochrane review on non invasive ventilation for acute asthma exacerbations states that this course of treatment remains controversial. No large randomized trial has evaluated the use of CPAP and asthma patients in the literature that exists.

The small trials looking at CPAP and asthma, concluded that there was no harm to its use, but no conclusive mortality benefit, or intubation benefit. The physiologic benefits of improved airflow and improved deposition of nebulize bronchodilators have not translated into a measurable change in clinical outcomes.

In the absence of demonstrated harm, the clinical benefits of improved gas exchange, decrease in respiratory muscle work, and possible improvements in aerosolized Bronco dilator delivery may justify a trial of non invasive ventilation in patients with asthma. So despite the lack of support from guidelines in the medical literature, there really is no demonstrable harm with the trial of non invasive ventilation in patients with acute exacerbations of asthma.

Hopefully, I've convinced you to consider a trial and IV for your next patient with an acute exacerbation of asthma. So hope you liked this video. Absolutely. Make sure to check out the course this video was taken from and to register for a free trial account which will give you access to select the chapters of the course. If you want to learn how Medmastery can help you become a great clinician, make sure to watch the about Medmastery video. So thanks for watching, and I hope to see you again soon. Bye.