Division of Pediatric Emergency, Critical Care, Pulmonology & Allergic Disorders

AN INTERESTING CASE OF REFRACTORY STATUS ASTHAMATICUS

28 Feb 2018

6 ½ year old male child presented with history of cough and cold for 5 days, rapid breathing since last 5 hours. Child was a diagnosed case of mild persistent asthma since last three years on intermittent therapy (nebulisation with steroids and β2 agonists).

Child was taken to outside hospital where at presentation he was found to be in respiratory distress (RR- 60/min, SpO2 – 77% with increased work of breathing and markedly diminished air entry). He was started on Oxygen inhalation, continuous nebulisation with β2 agonist and intravenous magnesium. However, child’s condition didn’t improve and ABG done after 30 minutes of initiation of therapy showed hypercapnia with respiratory acidosis (pH- 7.1, PCO2- 90, PO2- 120, HCO3- 28) so child was intubated and referred to us. Child was started on SIMV PRVC mode with TV-10ml/kg, RR-14, FIO2-50 % PEEP- 0,I:E:1:3. On these settings child had an auto PEEP of 12 with Ppeak of 45 and transairway pressure of 28. ABG sent showed pH- 6.8, PCO2-184, PO2-115, HCO-24. Child was started on nebulisation with β2 agonist, injection methylprednisolone, ketamine and aminophylline infusions. Chest X ray showed hyperinflated lung fields. However, child continued to have severe respiratory acidosis, pH remained below 7.0 and PCO2 remained above 130 thus he was initiated on veno-venous ECMO at 6 hours of admission. ABG normalised immediately after starting ECMO. Child continued to have severe bronchospasm with transairway pressures of around 25 and auto PEEP of 10, so we were unable to wean the child off ECMO support even after 36 hours after its institution.

In view of no improvement in bronchospasm, child was started on inhalation anaesthetic isoflurane (1 %). Bronchospasm improved within 3 hrs of starting isoflurane, auto PEEP decreased to 2, transairway pressure decreased to 10, air entry also improved. Child was successfully weaned off ECMO 12 hours after starting isoflurane. Child was extubated on day 6 of hospital stay. He was subsequently discharged and is currently healthy with no neurological deficits.

When providers are unable to meet clinical goals using the ventilator, extracorporeal membrane oxygenation (ECMO) may be used to provide or supplement gas exchange till the disease condition is reversed. ECMO adds oxygen and removes carbon dioxide from the blood.