Objective: Status asthmaticus is seen in 3-10 % of asthma patients and can cause near-fatal asthma attacks. A near-fatal asthma attack is defined as a severe exacerbation of asthma that may require mechanical ventilation associated with respiratory arrest, altered consciousness, and/or PaCO2 over 50 mmHg. Invasive mechanical ventilation is required in 30% of patients, and mortality is 8% in these patients. Although mechanical ventilation can often provide adequate oxygenation and ventilation, ventilator-associated lung injury may occur due to increased dynamic hyperinflation of the lung. Extracorporeal methods are indicated in patients whose respiratory failure couldn’t be healed with mechanical ventilation. This report presents a near-fatal asthma attack patient managed with an extracorporeal carbon dioxide removal filter (ECCO2R).
Case: A 22-year-old female patient with asthma was admitted to the emergency department with shortness of breath. Besides pharmacological treatment, the patient was deteriorated and intubated. The patient was admitted to the ICU. Blood gas analysis showed respiratory and metabolic acidosis (pH: 6.9, PaCO2: 132 mmHg, PaO2:99 HCO3: 19.5 mmol/L). Bilateral hyperinflation was seen on Chest X-Ray (image), and severe respiratory wheezing was heard in both lungs. Mechanical ventilator settings (PCV mode, FiO2:50%, PEEP:0 cmH2O, Pinspiryum:35 cmH2O, respiratory rate: I/E:1/3.5) were made to prevent barotrauma. Otopeep was measured as six cmH2O with an expiratory hold maneuver. The maximum tidal volume was measured as 250 ml. ECCO2R system was initiated for ongoing respiratory acidosis with a 4 L/min sweep gas flow. Half an hour after starting the ECCO2R system, blood gas analysis was normal (pH: 7.40, PaCO2: 36 mmHg, PaO2:184 mmHg, HCO3:23 mmol/L ). On day 4, the bronchospasm was resolved completely, and respiratory system compliance increased. The sweep gas flow rate was titrated down, and the device support was discontinued on day 5. The patient was extubated after a successful spontaneous breathing trial on day six and discharged.
Result: Extracorporeal devices could be helpful in near-fatal asthma attack that is hard to manage with invasive mechanical ventilation. In cases where oxygenation can be maintained with a mechanical ventilator, and persistent hypercapnia is present, patients could benefit from ECCO2R.