Management of Asthma and COPD Exacerbations in Adults in the ICU

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Abstract

Severe, life-threatening asthma and COPD exacerbations are managed commonly in the ICU and are associated with significant morbidity and mortality. It is important to understand the commonalities and differences in the diagnosis and management of these obstructive lung diseases to improve patient outcomes via evidence-based care. In this review, we first outline triggers of acute asthma and COPD exacerbations and an initial diagnostic evaluation and severity assessment. We then review the pathophysiologic features of asthma and COPD exacerbations and create a framework for the management of exacerbations in critically ill adult patients aimed at reducing airway inflammation, reversing bronchospasm, and, in severe cases, supporting patients with mechanical ventilation or advanced therapies until clinical improvement is achieved.

Key Points

  1. Triggers and Initial Assessment: Viral and bacterial infections are primary triggers of exacerbations, with additional contributions from air pollution, allergens, and medication nonadherence. Early recognition and differentiation from other conditions such as pneumonia and pulmonary embolism are crucial.
  2. Bronchodilator Therapy as First-Line Treatment: Short-acting beta-agonists (SABAs) and short-acting muscarinic antagonists (SAMAs) are the cornerstone of acute treatment, with nebulized administration preferred for critically ill patients.
  3. Systemic Corticosteroids for Inflammation Control: Prednisone 40–50 mg/day for 5–7 days is recommended for asthma and COPD exacerbations, while higher doses (>240 mg/day of methylprednisolone) should be avoided due to increased risk of treatment failure and complications.
  4. Noninvasive Ventilation (NIV) for COPD Exacerbations: NIV reduces the need for intubation, ICU length of stay, and mortality in COPD but should be used cautiously in asthma due to limited supporting evidence.
  5. Monitoring for Dynamic Hyperinflation: For patients on invasive mechanical ventilation, monitoring plateau pressure (Pplat) and intrinsic positive end-expiratory pressure (PEEPi) is crucial to preventing ventilator-induced lung injury.
  6. Oxygen Therapy Considerations: Oxygen should be titrated to maintain SpO₂ between 93-95% in asthma and 88-92% in COPD. Excess oxygen can worsen hypercapnia in COPD due to the Haldane effect.
  7. Adjunctive Therapies: Magnesium sulfate and ketamine may be considered for refractory cases, though evidence remains limited. Biologic therapies such as omalizumab and benralizumab show promise in asthma but require further study.
  8. Role of Extracorporeal Support: Venovenous ECMO may be beneficial for patients with life-threatening exacerbations and severe hypercapnia refractory to conventional therapies.
  9. Extubation Strategies: Patients with COPD benefit from post-extubation NIV or high-flow nasal therapy (HFNT) to reduce reintubation risk, whereas no clear guidance exists for asthma.
  10. Future Research Needs: There is a need for further randomized controlled trials to clarify the role of emerging therapies, refine mechanical ventilation strategies, and develop personalized treatment algorithms for asthma and COPD exacerbations.

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