SESSION TYPE: Airway Global Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: It is well recognized worldwide that asthmatics have a poor perception of the severity of their bronchospasm. In the emergency management of Status Asthmaticus fluid resuscitation is of paramount importance, in addition to limiting the effects of dynamic hyperinflation in the mechanically ventilated patient. The contribution of endobronchial mucus to refractory bronchospasm must not be underestimated.
CASE PRESENTATION: A 35 year old male was referred to an urban teaching hospital from an outlying hospital for further management of Status Asthmaticus with Type 2 respiratory failure. The patient had presented to an outlying hospital earlier that day with a history of a non productive cough for four days, associated with SOB, and chest tightness. The day prior to presentation , his SOB worsened until he was barely able to complete sentences. He denied any fever. The patient was non compliant with his Ventolin and Beclomethasone inhalers. He failed to improve despite repeat nebulizations with Ventolin, IV steroids, and IV MgSo4. Within an hour of arrival at the referral hospital he has worsening respiratory distress, and requires intubation and ventilation. ABG on 10L O2 , pH = 7.355, pO2 =54.8mmHg,pCO2 = 79.9 mmHg, HCO3 = 30.3mmols/l SaO2 = 95.2%. .In the ICU overnight his hypercapnia persists despite paralysis, and controlled ventilation. Different ventilation strategies to reduce dynamic hyperinflation are used, but the patient demises within 8 hours of admission to the ICU. Autopsy showed voluminous lungs with no evidence of infection, no pneumothorax. There was extensive mucus plugging of the tracheobronchial tree.
DISCUSSION: The patient's lungs on histology showed no evidence of a pneumonia.This case highlights how much we underestimate the contribution of mucus plugging to refractory bronchospasm. We are reminded of the large amount of endobronchial mucus produced from the goblet cell hyperplasia in asthma. Fluid resuscitation is of paramount importance in the emergency management of Status Asthmaticus. Literature review as far back as 1977 in JAMA Vol 238, No.11, in a case series out of University of Colorado Medical Centre , showed extensive mucous plugging at the autopsies of patients who died from Status Asthmaticus.
CONCLUSIONS: Extensive endobronchial mucus can obstruct the traheobronchial tree and contribute to refractory bronchospasm in Status Asthmaticus. Careful fluid resuscitation is as important as reducing the complications of dynamic hyperinflation in the emergency management of these patients.
1) Scoggin Charles,Sahnn S., Status Asthmaticus A Nine -Year Experience JAMA Sept 12, 1977, Vol 238 No11 1158-1162 .
2) Mansel J.Keith, et al Mechanical Ventilation In Patients With Acute Severe Asthma American Journal of Medicine, Vol 89, July 1990 42-47
3) Leatherman James W., et al Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Critical Care Medicine 2004, Vol.32 No.7 1542-1545
DISCLOSURE: The following authors have nothing to disclose: Althea Aquart-Stewart, May-Phyo Nyi Nyi
No Product/Research Disclosure InformationUniversity of the West Indies, Kingston, Jamaica