Status Asthmaticus and Pregnancy
OVERVIEW
- dangerous situation
- 2 patients
- complex
- need to call for help early
- pregnancy related issues are dependent on stage of pregnancy
-> first trimester: avoidance of teratogenicity
-> third trimester: management physiology of pregnancy - requires rapid assessment, resuscitation, treatment and consideration of best disposition for mother and baby.
STATUS ASTHMATICUS MANAGEMENT
Definition
- acute asthma that is refractory to medical management.
Medical treatment:
-> hydration
-> beta agonists (inhaled and iv)
-> steroids
-> Mg – consider foetus
-> non-invasive ventilatory support: CPAP and BIPAP
- indication for intubation: if respiratory failure, hypoxaemia, hypercapnia, exhaustion.
- high risk intubation: aspiration, difficult airway, narrow airway, worsening acidosis, cardiac arrest.
- difficulties ventilation and complication of ventilation: hyperinflation, pneumothorax, tension, cardiac arrest, increased airway pressures, need long expiratory time, watch intrinsic PEEP, high pressures may reflect raised intra-abdominal pressures.
PREGNANCY RELATED ISSUES
- call for help early
- multidisciplinary team approach: O&G, NICU, anaesthetics, ICU
Mother
- physiologic changes of pregnancy: respiratory/cardiovascular, aortocaval compression syndrome.
- need to be aware of the changes in blood gas reference values.
- need to position carefully -> ideally left lateral position.
- pregnancy can worsen asthma – pulmonary congestion, reflux disease, low FRC
- reduced respiratory reserve – > decompensation can be rapid
- hx of pregnancy: gestational age, singleton?, size of baby / polyhydramnios?
- does baby impair mothers state/ventilation
- protective ventilation and permissive hypercapnoea -> significant foetal acidosis
Foetus
- viable?
- lung development possible / betamethasone considered?
- effect of medication given to mother:
-> Steroids – potential malformations in the first trimester (cleft lip)
-> Beta 2 agonists – risk of tocolytic pulmonary oedema – delay in onset of labour
-> Benzodiazepines – floppy infant syndrome
-> Opiates – fetal respiratory depression
-> Prolonged paralysis – risk of arthrogryposis in the fetus
- maternal hypercapnia – reduces uteroplacental blood flow + shifts oxyHb dissociation curve in the fetus to the right
-> thus impairing fetal oxygenation – fetal monitoring essential - long term maternal hypoxia associated with IUGR
ENVIRONMENT
- adequate staff for moving of patient
- monitoring of baby (continuous CTG may be indicated)
- develop a plan for if mother or baby deteriorate.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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