In patients who have continued deterioration despite the above therapies, consultation is required. Additional therapies can be considered, but the prognosis is dim. 

Bilateral Needle thoracostomy 

In the patient who is deteriorating (and nearing or entering arrest), a possibility for unrecognized and bilateral tension pneumothoraxes exists. Treatment is with bilateral needle thoracotomy. 

Systemic Beta-agonists

IV isoproterenol can be administered in severe cases when patients cannot inhale bronchodilation therapy. The dose is 0.1 mcg/kg each minute to a maximum of 6 mcg/k each minute. Monitor heart rate and titrate accordingly. 

Inhaled Volatile Anesthetic

These medications cause significant smooth muscle relaxation. However, associated effects include vasodilation and cardiac depression. They can also lower the threshold for cardiac arrhythmias. It is vital that providers are knowledgeable and clinically experienced in their use before attempting this therapy. 

More information

Certain associations have developed useful guidelines and overview for managing asthma. More information can be found at: 

• Global Initiatives for Asthma: www.nhlbi.nih.gov/about/org/naepp 
• American Academy for Allergy Asthma and Immunology: www.aaaai.org/practice-resources/statements-and-practice-parameters/practice-parameter-guidelines
• National Asthma Education & Preventing Program: www.nhlbi.nih.gov/about/org/naepp