Veno-venous extracorporeal membrane oxygenation for ventilator sparing therapy in the management of a patient with severe refractory status asthmaticus

SESSION TITLE: Asthma, Eosinophilia, and Cough SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 09:40 am - 10:25 am INTRODUCTION: Once invasively mechanically ventilated, patients with status asthmaticus can often be challenging to manage. The bronchospasm and increased expiratory resistance can cause air trapping and increased levels of intrinsic positive end-expiratory pressure (PEEP). In these cases, extracorporeal membrane oxygenation (ECMO) can be used to help mitigate the risks associated with intrinsic PEEP and hyperinflation that can develop in the mechanical ventilation of these patients. CASE PRESENTATION: We present the case of a 24-year-old female with asthma who presented to the hospital with dyspnea. On arrival, she had a respiratory rate (RR) of 34 breaths/minute, sinus tachycardia with a heart rate of 153 beats/minute, and oxygen saturation of 86% on room air. She was treated with solumedrol, magnesium, and continuously nebulizer albuterol-ipratropium but was ultimately intubated and mechanically ventilated for ongoing respiratory distress and hypoxemia. She was initially ventilated with assist control/volume control (AC/VC) with tidal volume (Vt) 380cc, PEEP 10cm H2O, and RR 15 breaths/minute. On these settings, her peak and plateau pressures were elevated (75cm H2O and 26cm H2O respectively). She was sedated with propofol, ketamine, fentanyl, and received cisatracurium for neuromuscular blockade. While she continued to have respiratory acidosis (arterial blood gas [ABG]: 7.07/92/87), she also had incomplete expiration and an intrinsic PEEP of 14cm H2O that manifested as hypotension and bradycardia and required multiple ventilator circuit disconnections. Her acidosis continued to worsen despite multiple ventilator settings adjustments and the decision was made to initiate veno-venous (V-V) ECMO. She was cannulated with a 31-French, dual-lumen cannula inserted into the right internal jugular vein. Her flow was set to 3.0 liters per minute (LPM), and her sweep gas was initially set to 2 LPM but slowly increased to 4 LPM to avoid rapid correction of her hypercapnia. Within 24 hours, her ABG improved, and her ventilator settings were changed to achieve an I:E ratio of 1:28 leading to resolution of auto-PEEP. As her bronchospasm improved and her intrinsic PEEP decreased, her minute ventilation was progressively increased by increasing her Vt and RR and her ECMO flow and sweep gas were decreased. She was decannulated on ECMO day 11 and liberated from the ventilator on hospital day 20. DISCUSSION: In patients with severe status asthmaticus, invasive mechanical ventilation can be a potentially life-saving therapy. However, mechanical ventilation is also associated with potential risks in patients with status asthmaticus. In patients with severe status asthmaticus who cannot be adequately managed with invasive mechanical ventilation, or wherein the ventilator settings required for adequate CO2 clearance cause harm, V-V ECMO can be considered as a supplementary therapy. CONCLUSIONS: V-V ECMO is a tool that can potentially help mitigate the harms that are associated with bronchospasm, air trapping, and hyperinflation that can occur during invasive mechanical ventilation of patients with severe status asthmaticus. Reference #1: Laher AE, Buchanan SK. Mechanically Ventilating the Severe Asthmatic. Journal of Intensive Care Medicine. 2018;33(9):491-501. Reference #2: Garner O, Ramsey JS, Hanania NA. Management of Life-Threatening Asthma: Severe Asthma Series. Chest. 2022 Oct;162(4):747-756. Reference #3: Brodie D, Bacchetta M. Extracorporeal Membrane Oxygenation for Adults with ARDS. New England Journal of Medicine. 2011;365(20):1905-1914. DISCLOSURES: No relevant relationships by Yasin Khan No relevant relationships by Sandra Okoli No relevant relationships by Abigail Spaedy