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Bronchoscopy as a Rescue Therapy in Patients With Status Asthmaticus: Two Case Reports and Review of Literature FREE TO VIEW

Muhammad Khan, MBBS; Hadil Al Otair, MBBS; Abdul Aziz AlZeer, MD; Alaa Elgishy, MBBS
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King Khalid University Hospital, Riyadh, Saudi Arabia

Chest. 2014;145(3_MeetingAbstracts):3A. doi:10.1378/chest.1826982
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SESSION TITLE: Asthma Case Report Posters

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Management of status asthmaticus requires more than guidelines-guided therapy. Occasionally, unusual therapeutic interventions may provide significant benefits. The role of bronchoscopy in fatal asthma is still not clearly defined.

CASE PRESENTATION: A 43-year-old woman presented with acute severe asthma. Her initial arterial blood gases showed pH 6.90; PaCO2 114 mmHg; PaO2 30.0 mmHg; and HCO3 13.4 mEq/L.. . The patient was sedated with ketamine and relaxed with rocuronium infusion and placed on mechanical ventilation Lung mechanics revealed high-peak airway and plateau pressure . she was started with bronchodilators , inhaled and intravenous corticosteroids, and bolus of magnesium sulfate . Salbutamol infusion and intermittent doses of subcutaneous adrenaline were added. Urgent flexible bronchoscopy was performed for diagnostic purposes and removal of mucus plug as warranted.Immediately after bronchoscopy, the patient’s respiratory condition began to improve. A 36-year-old male, presented with severe acute asthma. Blood gases before intubation (pH 7.01; PaCO2 108; PaO2, 106 HCO3 27.8) Treatment included inhaled bronchodilators, inhaled and intravenous steroids, antibiotics, and a bolus dose of magnesium sulfate. Patient was placed on mechanical ventilation (Lung mechanics revealed high peak pressures and intrinsic PEEP) . Salbutamol Iinfusion and intermittent subcutaneous adrenaline was started . Bronchoscopy was performed and revealed inflamed airways and obstruction of middle-sized airways with mucus plugs that were removed. The patient was successfully weaned from mechanical ventilation on the following day.

DISCUSSION: The clinical course and severity of symptoms in asthma follows the sequence of air flow limitation leading to ventilation perfusion mismatch, hypoxemia, hypercarbia, and respiratory failure. infections and severe mucus plugging;may further worsen air flow obstruction, atelectasis,. It has already been observed[1)] that the necropsic finding of patients who died after fatal asthmatic attack revealed blockade of airway; primarily due to thick mucus plugs . . Early reports highlighted the successful use of bronchoscopy in patients with severe asthma who were on mechanical ventilation.[2,] Removal of mucus plugs helped in improvement of PCO2 and expedites ventilator withdrawal. A recent report of 41 pediatric patients showed improvement in ventilator weaning after performing therapeutic bronchoscopy.[3]

CONCLUSIONS: These two cases support that bronchoscopy may facilitate respiratory recovery in patients with resistant status asthmaticus who are on mechanical ventilation. Further studies are warranted to explore the potential role of bronchoscopy in these patients.

Reference #1: Houston JC, De Navasquez S, Trounce JR. A clinical and pathological study of fatal cases of status asthmaticus. Thorax 1953;8:207-13

Reference #2: Walker PE, Marshall M. Bronchial lavage in status asthmaticus. Br Med J 1969;3:31-2. Pulmonol 2012;47:1180-4.

Reference #3: Maggi JC, Nussbaum E, Babbitt C, Maggi FE, Randhawa I. Pediatric fiberoptic bronchoscopy as adjunctive therapy in acute asthma with respiratory failure. Pediatr

DISCLOSURE: The following authors have nothing to disclose: Muhammad Khan, Hadil Al Otair, Abdul Aziz AlZeer, Alaa Elgishy

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