SESSION TYPE: Critical Care Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Status asthmaticus is a life-threatening condition characterized by progressive respiratory failure due to asthma that may be unresponsive to standard therapeutic measure1. We describe a patient with status asthmaticus refractory to conventional medical therapy and ventilator management, who was rescued with timely use of extracorporeal membrane oxygenation therapy (ECMO).
CASE PRESENTATION: A 23 year old male, non -smoker, with the past history of mild intermittent asthma presented to the emergency department for exacerbation of asthma precipitated by an upper respiratory syndrome. His asthma symptoms had been previously controlled by as needed use of MDI albuterol alone. There was no history of hospitalization or intubation for asthma. Despite aggressive therapy with continuous albuterol, terbutaline, subcutaneous epinephrine, and high dose steroids, his symptoms progressed. He was intubated and transferred to the intensive care unit where he was sedated, paralyzed, and continued on mechanical ventilation. Chest radiograph showed severe hyperinflation. With recommended ventilator settings for status asthmaticus (low respiratory rate, low tidal volume, and prolonged expiratory phase) he remained extremely difficult to ventilate, generating high peak pressure (49cmH2O) and significant intrinsic PEEP (18cmH2O). Serial blood gases revealed worsening respiratory acidosis (pH 6.95: pCo2 112mmHg). Cardiothoracic surgery was consulted to initiate veno-venous ECMO (Avalon, 27 F Bi-Caval Dual lumen cannulated via the internal jugular vein and using a Quadrox D poly-methylpentene oxygenator). With ECMO, the respiratory acidosis gradually improved over the next few hours and mechanical ventilator settings were set at lung rest mode, with low tidal volumes. With continued use of steroids and inhaled bronchodilator therapy, the bronchospasm improved. ECMO was discontinued on hospital day two and patient was extubated on hospital day four.
DISCUSSION: Extracorporeal life support has been used as salvage therapy for adults with acute respiratory failure since 1972. Status asthmaticus, a potentially fatal but reversible process represents a disease which could benefit from extracorporeal gas exchange when standard measures have failed. Evidence supporting the use of ECMO in refractory status asthmaticus is lacking, and only a few case reports exist. Novel modalities like pECLA( pumpless extracorporeal lung assist) are being increasingly utilized in similar acute respiratory failures.
CONCLUSIONS: The application of extracorporeal gas exchange can be lifesaving in refractory status asthmaticus.
1) Cohen NH, Eigen H, Shaughnessy TE. Status asthmaticus. Crit Care Clin. 1997 Jul;13(3):459-76. Review. PubMed PMID: 9246526.
DISCLOSURE: The following authors have nothing to disclose: Narendrakumar Alappan, Lewis Eisen, William Jakobleff, Ariel Shiloh
No Product/Research Disclosure InformationMontefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY