Sevoflurane To The Rescue: A Convoluted Case Of Respiratory Failure In An Asthmatic Teenager

INTRODUCTION: We present a case of a medically nonadherent 16 years-old female with a history of moderate persistent asthma and vaping of nicotine and marijuana products who presented in severe respiratory distress during the COVID-19 pandemic She had poor response to continuous inhaled albuterol, scheduled intermittent ipratropium, systemic steroids, intravenous magnesium, and non-invasive ventilator support which led to intubation and mechanical ventilation Because of ongoing bronchospasm, heliox, terbutaline, and ketamine infusions were initiated, but she continued to exhibit worsening respiratory failure, poor lung compliance, and severe bronchospasm She then developed hypotension requiring an epinephrine infusion Given this picture, sevoflurane (SEVO) was initiated resulting in an immediate clinical response with normalization of blood gases and lung compliance without any adverse effects METHODS: SEVO was titrated to effect between 1-3% over the next 24 hours Multiple attempts to wean off SEVO were unsuccessful despite the addition of an aminophylline infusion She received SEVO for a total of 96 hours and mechanical ventilation for 11 days Extensive evaluation revealed chest x-ray with mild left lower lobe infiltrates, an otherwise negative CT chest, and negative workups for COVID-19, respiratory and blood cultures, allergic bronchopulmonary aspergillosis, sarcoidosis, and leptospirosis An echocardiogram was obtained and she was found to have a trabeculated myocardium, with an ejection fraction (EF) <30% and LV non-compaction She later developed critical illness myopathy, which improved with rehabilitation, and upon repeat echo she did not meet the criteria for non-compaction with 71% EF and her BNP had normalized She was discharged home after 27 days and her clinical picture was most consistent with a severe asthma exacerbation likely due to noncompliance and vaping RESULTS: SEVO is commonly used for anesthesia in children, and is known for its bronchodilation properties, but its use in pediatric critical care settings is rarely described Our patient tolerated SEVO well and it was indeed a life saving measure that was used successfully in the PICU, avoiding the need for ECMO This case supports using SEVO in patients with severe asthma who have failed conventional therapy