SESSION TYPE: Critical Care Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM – 02:30 PM
INTRODUCTION: Refractory status asthmaticus represents a considerable challenge in the intensive care unit. Progressive respiratory failure due to asthma in which conventional forms of therapy have failed carries significant morbidity and mortality. We present a case of refractory status asthmaticus in which several non-standard treatments were successfully utilized, including extracorporeal membrane oxygenation (ECMO) and inhaled anesthetics.
CASE PRESENTATION: 34 year old African American female transferred to our facility with an acute asthma exacerbation necessitating mechanical ventilation. Examination on admission was notable for diffuse bilateral expiratory wheezing and tachycardia. Arterial blood gas showed an acute respiratory acidosis. Respiratory viral PCR was positive for rhinovirus/enterovirus. Chest radiograph showed marked hyperinflation without focal opacity. In addition to mechanical ventilation, she was started on aggressive inhaled bronchodilator therapy and systemic corticosteroids. Despite standard therapy, she developed elevated peak and plateau pressures and intrinsic PEEP leading to impaired ventilation and hemodynamic compromise. Her condition deteriorated despite addition of ketamine, paralytics, and ventilator adjustments. Veno-venous ECMO was initiated. Intravenous treatments were attempted including aminophylline and terbutaline without significant effect or harm. Ultimately, she seemed to clinically improve after introduction of inhaled isoflurane with dramatic resolution of her intrinsic PEEP and improved ventilator parameters. ECMO was discontinued after 9 days. Her course was complicated by critical care polyneuropathy and failure to wean requiring tracheostomy. She was subsequently weaned from ventilatory support, decannulated, and discharged to a sub-acute rehabilitation facility.
DISCUSSION: Standard therapy for severe status asthmaticus includes bronchodilators, systemic corticosteroids, and often mechanical ventilation. Despite standard therapy, some patients remain refractory necessitating adjunctive treatments with evidence limited to small clinical trials and case reports. Our case illustrates the utility of several non-standard interventions in a critically ill patient. While ECMO provided essential supportive care, there appeared to be an acute and dramatic improvement with addition of inhaled isofluorane.
CONCLUSIONS: Management of severe refractory status asthmaticus in the critical care setting occasionally requires both standard and adjunctive therapies. ECMO was successfully used for patient support while other medications were given time to work. Inhaled isoflurane is the volatile anesthetic of choice, and has been shown to dramatically improve bronchial hyperactivity in small case studies.
1) Outcomes Using Extracorporeal Life Support For Adult Respiratory Failure Due to Status Asthmaticus. ASAIO J. 2009; 55(1):47-52.
2) Isoflurane Therapy for Status Asthmaticus in Children and Adults. CHEST 1990;97:698-701.
DISCLOSURE: The following authors have nothing to disclose: Clayton Shamblin, Matthew Divietro, Charlie Strange, John Huggins
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Medical University of South Carolina, Charleston, SC