Extracorporeal membrane oxygenation (ECMO) for near-fatal asthma refractory to conventional ventilation.

We describe a case of near-fatal asthma, treated successfully by initiation of extracorporeal membrane oxygenation (ECMO). A 29-year-old woman, known asthmatic on steroid inhalers, inhaled/nebulised bronchodilators, long-term oral prednisolone, theophylline and montelukast, presented with acute shortness of breath. She deteriorated following initial treatment with nebulised bronchodilators and magnesium sulfate requiring intubation and mechanical ventilation. Severe bronchospasm ensued following mechanical ventilation and peak airway pressures remained at 55 cm H2O with intrinsic positive end expiratory pressure(PEEP) of 14 cm H2O. Despite treatment with sedation, paralysis, intravenous salbutamol and inhaled sevoflurane, her condition deteriorated. She was commenced on mobile ECMO by the retrieval team. While on ECMO, her CO2 normalised within 48 hours. She was extubated within 72 hours of initiating ECMO and was discharged to the ward next day. We reiterate that ECMO should be considered sooner for status asthmatics not responding to maximal pharmacological therapy and ventilatory support to prevent ongoing lung injury and mortality.

Emergence of oseltamivir-resistant pandemic H1N1 in an immunocompetent child with severe status asthmaticus.

INTRODUCTION: Pandemic influenza A (H1N1) may cause severe illness in pediatric patient with chronic lung disease. CASE REPORT: We describe the emergence of oseltamivir resistance in an immunocompetent child with status asthmaticus triggered by pandemic influenza A (H1N1). This case highlights the possible relationship between influenza viral load and risk of resistance emergence in children with asthma. Influenza vaccination should continue to be emphasized as the mainstay of prevention in children with chronic lung disease. CONCLUSION: Influenza virus can lead to severe status asthmaticus and can develop oseltamivir resistance in immunocompetent children.

The clinical significance of lung hypoexpansion in acute childhood asthma.

BACKGROUND: Many children experiencing acute asthmatic episodes have chest radiographs, which may show lung hyperinflation, hypoinflation, or normal inflation. Lung hypoinflation may be a sign of respiratory fatigue and poor prognosis. OBJECTIVE: To compare the clinical course in children with asthma according to the degree of lung inflation on chest radiographs. PATIENTS AND METHODS: We conducted a retrospective study during a 24-month period (from July 1999 to July 2001) of children aged 0-17 years, who presented to a pediatric emergency department or outpatient clinic with an asthma exacerbation. Chest radiographs obtained at presentation were reviewed independently by three pediatric radiologists who were blinded to the admission status of the patient. The correlation between hypoinflation and hospital admission was assessed in three age groups: 0-2 years, 3-5 years, and 6-17 years. RESULTS. Hypoinflation on chest radiographs was significantly correlated with hospital admission for children aged 6-17 years (odds ratio 16.00, 95% confidence interval 1.89-135.43). The inter-reader agreement for interpretation of these radiographs was strong, with a kappa score of 0.76. Hypoinflation was not correlated with admission in younger children. CONCLUSION: Lung hypoinflation is associated with a greater likelihood of hospital admission in children aged 6 years or older. Therefore, hypoinflation was a poor prognostic sign and may warrant more aggressive therapy.

Sinusitis in status asthmaticus.

The relationship between sinusitis and status asthmaticus (SA) remains obscure. The purposes of this study were to determine the prevalence of abnormal sinus radiographs (SXRs) and investigate possible risk factors among unselected children admitted with SA. Eighty-eight patients over 2 years of age (range 2 to 16 years) consecutively admitted with SA were studied. The principal investigator, blinded to SXR findings, interviewed and examined the patients with respect to 10 physical parameters and 14 historical parameters. Two staff radiologists, blinded to the clinical findings, interpreted the SXRs. Relationship of historical and physical findings with positive SXRs was determined by statistical analysis. Twenty-seven percent of patients were found to have abnormal SXRs, manifesting two thirds or greater opacification of the sinuses. The mean age, sex, and race of patients with abnormal SXRs was not significantly different from those with normal films. A history of two or more admissions per year for SA, and, in children under 5 years of age, a history of chronic otitis media, and the physical finding of otitis media were significantly more frequent among patients with abnormal SXRs. Although not found to be statistically significant, a history of sinusitis and cough occurred more frequently in association with abnormal SXRs.

[Plethysmographic and radiologic measurement of the total lung capacity during acute attack of bronchial asthma]. / Medición pletismográfica y radiológica de la capacidad pulmonar total durante un ataque agudo de asma bronquial.

There is controversy on the behavior of total lung capacity (TLC) during an acute asthma attack because the severe airflow obstruction causes an overestimation of the intrathoracic gas measured by plethysmography. We measured plethysmographic and radiologic TLC (TLCpl, TLCrx) in 17 patients with acute asthma, at admission and 3-5 days later when clinical and spirometric improvement was seen. TLCrx was measured planimetrically from routine chest X-rays in postero-anterior and lateral projection. Patients had a mean age of 32 +/- 15 years (ranging from 8-53) and six were males. FEV1 and FVC increased significantly in the second evaluation (1.36 +/- 0.7 vs 1.99 +/- 0.7 L, and 1.97 +/- 0.9 vs 2.6 +/- 1 L respectively, p less than 0.05), whereas airway resistance decreased (13.4 +/- 5.3 vs 9.8 +/- 3.4 cm H2O/L/s, p less than 0.05). On the other hand, we did not find a significant change in TLCpl (4.4 +/- 1.1 vs 4.6 +/- 1.2 L) nor in TLCrx (4.2 +/- 0.9 vs 4.1 +/- 0.8 L). We found no significant difference between TLCpl and TLCrx.

[Subcutaneous emphysema in status asthmaticus]. / Das subkutane Emphysem im Rahmen des Status Asthmaticus.

Spontaneous subcutaneous accumulations of air in the soft parts of the thorax during an asthmatic crisis (status asthmaticus) are rarely seen. The pathomechanism of the phenomenon, which may lead to the formation of an emphysema of the soft parts via the pneumomediastinum, is discussed, and the possible complications which must be taken into account are pointed out. The value of radiological examination of the thorax in children suffering from asthma bronchiale, is explained briefly.

[Chests x-ray in status asthmaticus. Relations between radiological abnormalities and impaired respiratory function]. / L'esame radiologico del torace nello stato di male asmatico. Relazione fra anormalità radiologiche e compromissione della funzione respiratoria.

The chest radiographs of 78 adult asthmatic patients admitted with severe acute asthma over a three-years period were reviewed. Radiographic findings were compared with functional data. Overinflation was demonstrated in 32% of chest X-rays. In four patients the presence of atelectasis was shown. On admission only PaO2 was significantly lower in patients with radiological abnormalities than in patients with normal chest radiographs. The usefulness of chest radiographs in patients with acute asthma is discussed.