Extracorporeal Membrane Oxygenator Support in a Case of Severe Status Asthmaticus

doi:10.1016/S0003-4975(10)61538-X

The Annals of Thoracic Surgery

Volume 31, Issue 2, February 1981, Pages 171-175

https://doi.org/10.1016/S0003-4975(10)61538-X Get rights and content

Abstract

Support with extracorporeal membrane oxygenation (ECMO) can sustain life for a substantial period of time, but the role of long-term ECMO support is limited. The National Institutes of Health ECMO collaborative study revealed no significant reduction in mortality in adults with severe respiratory distress syndrome treated with ECMO. The value of ECMO in the treatment of transient, severe acute respiratory insufficiency has been demonstrated in patients after cardiac operations, in patients with Pneumocystis carinii pneumonia, and in patients following trauma. We present an example of refractory respiratory failure in a young asthmatic with massive atelectasis in whom the institution of ECMO allowed us to perform adequate pulmonary lavage. It resulted in improvement in gas exchange and the patient's survival.

References (20)

JD Cooper et al.
Cannulation of ascending aorta for long-term membrane oxygenator support
J Thorac Cardiovasc Surg
(1975)
GW Geelhoed et al.
The role of membrane lung support in transient acute respiratory insufficiency of Pneumocystis carinii pneumonia
J Thorac Cardiovasc Surg
(1974)
P Marchand et al.
Last resort treatment of status asthmaticus
Lancet
(1966)
JR Soeter et al.
Prolonged extracorporeal oxygenation for cardiorespiratory failure after tetralogy correction
J Thorac Cardiovasc Surg
(1973)
WM Zapol et al.
Extra corporeal perfusion for acute respiratory failure: recent experience with the spiral coil membrane lung
J Thorac Cardiovasc Surg
(1975)
J Ambiavagar et al.
Resuscitation of the moribund asthmatic
Anesthesia
(1967)
RK Bartlett et al.
Extracorporeal circulation for cardiopulmonary failure
Curr Probl Surg
(1978)
JD Cooper
Combination of pulmonary lavage and extracorporeal membrane oxygenator support
RF Fallat et al.
Clinical hemodynamics and gas exchange by three extracorporeal membrane oxygenation cannulation methods
MI Gold et al.
Pulmonary mechanics during general anesthesia: V. Status asthmaticus
Anesthesiology
(1970)

There are more references available in the full text version of this article.

Cited by (37)

Extracorporeal carbon dioxide removal in heart-beating donor with acute severe asthma: A case report
2020, Respiratory Medicine Case Reports
Citation Excerpt :
In literature, ECMO is generally recommended in the setting of potentially reversible cardiopulmonary failure that is poorly responsive to maximal conventional medical treatment. However, although literature is confined to a few case reports [20,21], a recent review of the multicenter International Extracorporeal Life Support Organization registry by Mikkelsen and colleagues [22] documented that status asthmaticus was the primary indication for ECMO in 24 of 1257 adult patients included in the registry. A total of 20 (83.3%) patients with asthma survived to hospital discharge, whereas only 50.8% of patients with other causes of respiratory failure (odds ratio 4.86) survived therapy.
Status asthmaticus is a life-threatening disorder that can manifest in dangerous levels of hypercapnia and acidosis. The use of extracorporeal carbon dioxide removal (ECCO2R) has been used successfully to control pH and PaCO₂ in patients with acute severe asthma. The present report describes the use of this technology in near-fatal asthma with brain death, and awaiting organ harvest.
The ProLUNG® system consists of a veno-venous hemoperfusion circuit with an artificial lung polymethylpentene membrane coated with phosphorylcholine with a surface of 1.81 m². The system can reach a blood flow of 450 ml/min trough a double-lumen central venous catheter (13.0 Fr) placed in femoral, subclavian or jugular vein. The platform is provided with automated management of airflow and VCO₂ monitoring during treatment.
The patient was maintained on extracorporeal treatment ensuring stable arterial pH control and PaCO₂ control.
In acute status asthmaticus, complicated with cardiac arrest, mini-invasive ECCO2R was an effective method of controlling pH and PaCO₂, for optimizing hemodynamic and aerobic metabolism and for performing protective ventilation for an optimal organ donor preservation until the organ harvest occurs.
Emergency treatment of status asthmaticus with enoximone
2014, British Journal of Anaesthesia
Citation Excerpt :
Mechanical ventilation may ultimately be necessary but may introduce a host of complications, such as ventilator-related infections and mechanical lung tissue damage. Ventilatory treatment for refractory asthma can go as far as inhalation anaesthetics such as sevoflurane and extracorporeal carbondioxide extraction and oxygenation [by extra corporeal membrane oxygenator (ECMO)].18 19 When intubation cannot be avoided, it usually takes 3–5 days before the bronchoconstriction becomes less severe and weaning from the ventilator can be initiated.
This report describes the treatment of eight patients with status asthmaticus, six of whom were already maximally treated. They were consequently treated with enoximone, a selective phosphodiesterase III inhibitor, in their refractory phase. Bronchodilatation in these patients was immediate. No side-effects were observed. Enoximone appears to be a valuable addition to the treatment of status asthmaticus. I.V. administration bypasses inhalation incapability in severe asthma. It is likely to reduce or altogether prevent the need for resorting to secondary or tertiary high-tech therapy such as mechanical ventilation or anaesthetics, thus avoiding complications, as well as for transfers to specialized intensive care units. Not only do these aspects enable substantial cost savings, but they also may spare the patient a lot of anguish and a prolonged recovery.
Status asthmaticus in children: A review
2001, Chest
Citation Excerpt :
As ketamine increases cerebral blood flow through cerebral vasodilatation,218 this drug should be used with caution in patients who have other risk factors for intracranial hypertension, such as having suffered hypoxic-ischemic arrest or having severe hypercarbia. Extracorporeal life support (ECLS) has occasionally been reported219,220,221,222 as last resort in refractory status asthmaticus. ECLS remains an experimental, expensive, and invasive therapy in asthma.
About 10% of American children have asthma, and its prevalence, morbidity, and mortality have been increasing. Asthma is an inflammatory disease with edema, bronchial constriction, and mucous plugging. Status asthmaticus in children requires aggressive treatment with β-agonists, anticholinergics, and corticosteroids. Intubation and mechanical ventilation should be avoided if at all possible, as the underlying dynamic hyperinflation will worsen with positive-pressure ventilation. If mechanical ventilation becomes necessary, controlled hypoventilation with low tidal volume and long expiratory time may lessen the risk of barotrauma and hypotension. Unusual and nonestablished therapies for severe asthma are discussed.
Status asthmaticus
1997, Critical Care Clinics
Asthma is a common clinical condition characterized by wheezing, dyspnea, and cough resulting from reversible airflow obstruction. Histopathologic evidence over the past 30 years has emphasized the prominent role of airway inflammation, in conjunction with smooth muscle–mediated bronchoconstriction and intraluminal mucus as integral to the pathogenesis of this disorder.
The care of the patient with asthma is challenging, even to the most experienced clinician. The diagnosis of asthma is not straightforward and the clinical presentation is variable. Many patients with asthma can be managed satisfactorily through a combination of education about the disease process, potential inciting events, and ways to minimize them, as well as appropriate use of medications to prevent and control bronchospasm. For some patients, however, management can be difficult. Some patients do not receive adequate, early treatment, so that symptoms progress to life-threatening asthma. Others deteriorate in spite of aggressive treatment. As a result of the disease progression, patients develop status asthmaticus, life-threatening asthma characterized by progressive respiratory failure refractory to usual therapeutic interventions. Many of these patients require management in an intensive care unit, tracheal intubation, and mechanical ventilatory support. This article defines the pathophysiology of asthma and status asthmaticus in children and adults, describes clinical management options, and defines how to integrate an understanding of the disease process into a rational plan of management.
Near-fatal pediatric asthma managed with pumpless arteriovenous carbon dioxide removal
2007, Critical Care Medicine
To describe the use of pumpless arteriovenous carbon dioxide removal in support of four pediatric patients with near-fatal asthma.
Report of four cases.
Tertiary care university pediatric intensive care unit.
Four pediatric patients, ages 4, 10, 12, and 13, were intubated and initially managed with positive pressure ventilation for severe respiratory failure. Despite pharmacologic therapy with inhaled β-agonists, inhaled anticholinergics, systemic corticosteroids, and intravenous magnesium, marked progressive hypercapnia and acidosis rapidly developed requiring high levels of positive pressure ventilation.
Application of pumpless arteriovenous carbon dioxide removal (AVCO₂R) via percutaneous femoral cannulation.
Arterial or mixed venous carbon dioxide partial pressure (Pco₂) and pH were measured before and at intervals following initiation of AVCO₂R. Before cannulation, Pco₂ was elevated to 100, 108, 90, and 186 mm Hg in the four patients, with corresponding pH of 7.07, 6.96, 7.09, and 6.80, respectively. Pco₂ levels were reduced to more acceptable levels (37–57 mm Hg) within 2–4 hrs of initiation of AVCO₂R, with corresponding improvements in pH despite reductions in ventilatory frequency and tidal volumes to safe levels. Duration of support ranged from 18 hrs to 5 days during resolution of bronchospasm. No red blood cell or platelet transfusions were required, and no complications resulted from AVCO₂R or from mechanical ventilation. All patients were discharged from the hospital without sequelae.
Percutaneous cannulation with a simplified pumpless extracorporeal circuit is capable of removing sufficient carbon dioxide to allow application of a protective ventilatory strategy in severe hypercapnic pediatric respiratory failure. The procedure was safely applied without complications in four pediatric patients as young as 4 yrs of age.
Near-fatal pediatric asthma managed with pumpless arteriovenous carbon dioxide removal: Help at the margin
2007, Critical Care Medicine

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: We thank Mary Lewis, Patrick Trainor, and all the other members of the ECMO team; as well as the physicians, surgeons, and nursing and technical personnel for the excellent and coordinated clinical care given to our patient.

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The Annals of Thoracic Surgery

Abstract

References (20)

Cannulation of ascending aorta for long-term membrane oxygenator support

J Thorac Cardiovasc Surg

The role of membrane lung support in transient acute respiratory insufficiency of Pneumocystis carinii pneumonia

J Thorac Cardiovasc Surg

Last resort treatment of status asthmaticus

Lancet

Prolonged extracorporeal oxygenation for cardiorespiratory failure after tetralogy correction

J Thorac Cardiovasc Surg

Extra corporeal perfusion for acute respiratory failure: recent experience with the spiral coil membrane lung

J Thorac Cardiovasc Surg

Resuscitation of the moribund asthmatic

Anesthesia

Extracorporeal circulation for cardiopulmonary failure

Curr Probl Surg

Combination of pulmonary lavage and extracorporeal membrane oxygenator support

Clinical hemodynamics and gas exchange by three extracorporeal membrane oxygenation cannulation methods

Pulmonary mechanics during general anesthesia: V. Status asthmaticus

Anesthesiology

Cited by (37)

Extracorporeal carbon dioxide removal in heart-beating donor with acute severe asthma: A case report

Emergency treatment of status asthmaticus with enoximone

Status asthmaticus in children: A review

Status asthmaticus

Near-fatal pediatric asthma managed with pumpless arteriovenous carbon dioxide removal

Near-fatal pediatric asthma managed with pumpless arteriovenous carbon dioxide removal: Help at the margin