Bronchoscopy as a rescue therapy in patients with status asthmaticus: Two case reports and review of literature
A 36-year-old male, who was asthmatic since childhood, presented in the ED with shortness of breath for 1 week. The patient also had a history of yellowish sputum with fever for 1 week. Clinical exam revealed bilateral wheeze with prolonged expiration throughout the chest and a roentgenogram showed hyper-inflated lungs and right lower lobe infiltrate. He was intubated in the ED in response to worsening respiratory failure. The initial diagnosis was exacerbation of asthma and community acquired pneumonia. Blood gases before (pH 7.01; PaCO2 108; PaO2, 106 HCO3 27.8) and after the intubation showed acute respiratory acidosis (pH 7.16; PaCO2 90.2; PaO2 110; HCO3 23.7). Initial treatment included inhaled bronchodilators, inhaled and intravenous steroids, antibiotics (ceftriaxone and azithromycin), and a bolus dose of magnesium sulfate. Patient was placed on mechanical ventilation (Draeger infinity 500) with settings of assist control, rate 12 per min; tidal volume 6-7 mL/kg; PEEP 05 cm H2O; inspiratory flow rate 70 L/min and FiO2 1.0. Lung mechanics revealed high peak and plateau pressures of 70 and 28 cm H2O respectively, whereas intrinsic PEEP (PEEPi) was measured 12 cm H2O. Inspiratory flow rate was increased to 80 L/min to reduce the PEEPi.\nIntravenous infusion of salbutamol and intermittent subcutaneous adrenaline 0.5 mL (1:1000) was started due to progressive worsening of clinical condition. PEEPi and peak airway pressure improved from 12 to 4 cm H2O and 70 to 56 cm H2O respectively. Arterial blood gases showed little improvement (pH 7.26; PaCO2 74.9; and PaO2 146). On 3rd day of hospital admission bronchoscopy was planned for bronchial toilet. It revealed inflamed airways and obstruction of middle-sized airways with mucus plugs []. Effective suction and lavage were done.\nThe patient's clinical condition and ventilator requirement were reduced and ABG was improved [] after therapeutic bronchoscopy. The patient was successfully weaned on the following day. Patient was discharged from intensive care 48 h after extubation.