Feb 2, 2026
Contributor: Alec Coston, MD
Educational Pearls:
- BiPAP is often effective in severe asthma, but many patients struggle with mask tolerance due to intense air hunger–driven anxiety, often compounded by hypoxia.
- Benzodiazepines are commonly used for anxiety, but they can depress respiratory drive, making clinical improvement difficult to interpret (a lower RR may reflect sedation rather than true physiologic improvement).
- Low-dose fentanyl is a useful alternative when patients cannot tolerate BiPAP despite coaching.
- Opioids blunt the perception of dyspnea and are well established for treating air hunger.
- When carefully titrated, fentanyl provides anxiolysis without significant respiratory suppression.
- It is rapidly titratable (e.g., 25 mcg IV every 5 minutes).
- Evidence primarily comes from palliative and oncology literature, but growing clinical experience supports its use in severe asthma to improve BiPAP tolerance.
- Failure of fentanyl should prompt escalation to ketamine, often signaling impending need for intubation.
References
- Pang GS, Qu LM, Tan YY, Yee AC. Intravenous Fentanyl for Dyspnea at the End of Life: Lessons for Future Research in Dyspnea. Am J Hosp Palliat Care. 2016 Apr;33(3):222-7. doi: 10.1177/1049909114559769. Epub 2014 Nov 25. PMID: 25425740.
Summarized and edited by Meg Joyce, MS2
Donate: https://emergencymedicalminute.org/donate/
Join our mailing list: http://eepurl.com/c9ouHf
