Bronchoscopy as a rescue therapy in patients with status asthmaticus: Two case reports and review of literature
A 43-year-old woman, known to have asthma for 5 years, is presented to the Emergency Department (ED) in a gasping state. Her clinical assessments include: heart rate, 140 bpm; blood pressure, 70/42 mmHg; respiratory rate, 35 per min; and SpO2 78% on plethysmography. Initial resuscitation was done with intubation and fluid management. Her initial arterial blood gases showed severe respiratory and metabolic acidosis (pH 6.90; PaCO2 114 mmHg; PaO2 30.0 mmHg; and HCO3 13.4 mEq/L). After securing the airway, the clinical exam revealed, tachycardia, unstable hemodynamics, peripherally mottled skin, and silent chest with no air entry. The case was diagnosed as a severe life-threatening asthma leading to type II respiratory failure and shock. Initial laboratory exams showed hemoglobin, 13.4 g/dL; hematocrit 40.8%; leukocyte count 15.7 × 109/L and platelet 225 × 109/L. Chest X-ray revealed hyper-inflated lung fields. The patient was sedated with ketamine and relaxed with rocuronium infusion. She was placed on mechanical ventilation (Draeger C500) in assist control mode, respiratory rate 12 per min; tidal volume 7 mL/kg (according to ideal body weight); inspiratory flow rate 70 L/min; Positive end expiratory pressure (PEEP) 5 cm H2O; and 1.0 FiO2. Lung mechanics revealed high-peak airway and plateau pressure (80 and 30 cm H2O respectively). The Intrinsic-PEEP (PEEPi) measured at that time was non-significant. The treatment was started with bronchodilators (salbutamol and ipratropium), inhaled and intravenous corticosteroids, and bolus of magnesium sulfate (2 g).\nSubsequently, the patient was treated with salbutamol infusion and intermittent doses of 0.5 mL (1:1000) subcutaneous adrenaline. Despite being on maximum support, the patient showed no significant improvement. Lung mechanics still displayed high peak and plateau pressures (75 and 35 cm H2O respectively). Bicarbonate infusion was started to maintain the pH near normal. The patient continued to have mixed acidosis with pH 7.01; PCO2, 71.8; PaO2 87; and HCO3 13.4. Urgent flexible bronchoscopy was performed for diagnostic purposes and removal of mucus plug as warranted. Bronchoscopy revealed hyperemic airways, purulent secretions in central airways. Lavage was done and mucus plugs were removed. The process of bronchoscopy was unremarkable.\nImmediately after bronchoscopy, the patient's respiratory condition began to improve. Acidemia improved from 7.01 to 7.24, PCO2 decreased from 72 to 32 mmHg and PaO2 improved from 87.2 to 186 mmHg []. FiO2 was also reduced from 1.0 to 0.4. Peak and plateau airway pressures decreased to 25 and 18 cm H2O respectively. Patient's severe bronchospasm had remarkably improved.\nAt the same time, the patient was also treated for sepsis. The presence of Gram-positive cocci in blood was noted in gram stains and vancomycin was started. Hematological assessment showed elevated leukocyte (21.2 × 109/L), low platelet (98 × 109/L) count, and normal hemoglobin.\nFurthermore, patient's sepsis worsened. Patient was resuscitated with fluids, vasopressor, and broad spectrum antibiotics. Despite improvement in respiratory status her course was complicated with septic shock and multi-organ failure. Patient expired after 5 days of admission.