Ann Thorac Surg 1996;62:885-887
© 1996 The Society of Thoracic Surgeons
Case Report
Clinical Use of Extracorporeal Lung Assist for a Patient in Status Asthmaticus
Masahito Sakai, MD,
Hitoshi Ohteki, MD,
Kazuyosi Doi, MD,
Yasusi Narita, CE
Department of Cardiovascular Surgery, Saga Prefectural Hospital Koseikan, Saga, Japan
Accepted for publication April 5, 1996.
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Abstract
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A 23-year-old man was transferred to our hospital in an unconscious state due to hypercapnea with massive subcutaneous emphysema secondary to status asthmaticus. Mechanical ventilation was ineffective for removal of carbon dioxide and oxygenation. After the initiation of extracorporeal lung assist the patient was able to effectively clear his secretions. This resulted in marked improvement in his pulmonary compliance. There were no hemorrhagic pulmonary or hematologic complications. This is the first patient in whom we have used venovenous bypass in the treatment of status asthmaticus.
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Introduction
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A 23-year-old man was admitted to the hospital with bronchial asthma. Two days later, he became progressively dyspneic and cyanotic, which required endotracheal intubation and mechanical ventilation.
He was transferred to our hospital and treated with continuous positive-pressure ventilation with inhalation anesthesia. Conventional continuous positive-pressure ventilation failed to provide adequate respiration, and his pulmonary compliance remained poor with bronchodilators and steroids. The peak airway pressure was around 70 cm H2O with a tidal volume of 8 mL/kg and a respiratory rate of 20 breaths/min. The decision was made to employ extracorporeal lung assist (ECLA) 15 hours after the patient's arrival, when arterial blood gas analysis revealed a carbon dioxide tension of 100 mm Hg and an oxygen tension of 50 mm Hg. The ventilator settings included an inspired oxygen concentration of 1.0, no positive end-respiratory pressures, a tidal volume of 400 mL, and a respiratory rate of 30 breaths/min. Despite these measures, there was a persistent respiratory acidosis (pH = 7.02), a decreasing arterial ketone body ratio, a subcutaneous emphysema of the chest wall and neck, and progressively decreasing urine output. After systemic heparinization (1 mg/kg), a polyurethane catheter (Medikit 22F) was inserted into the inferior vena cava through the femoral vein for blood drainage using the percutaneous Seldinger technique, and another catheter (Medikit 18F, Tokyo, Japan) was inserted into the right atrium via the other femoral vein for blood return. The ECLA system included a centrifugal pump (Biomedicus, Eden Prairie, MN) and a silicone membrane artificial lung (Ultrox2; SciMed Co Ltd) with a surface area of 3.5 m2. The prime consisted of 800 mL of lactated Ringer's solution. The main bypass blood flow was between 1.7 and 2.0 L/min. The activated coagulation time was maintained at greater than 200 seconds by additional doses of Argatroban injection (Novastan, Tokyo Tanabe Co Ltd, Tokyo, Japan). The ventilator mode was changed from controlled mechanical ventilation to intermittent mandatory ventilation at 3 breaths/min without any sedation.
About 2 hours after the start of ECLA, the patient was able to clear secretions from the airway. In addition, the wheezing resolved. The arterial carbon dioxide tension decreased from 90 to 46 mm Hg, and the pulmonary compliance improved. The pH returned to normal, and the arterial ketone body ratio improved. The urine output rose dramatically from an hourly mean of 10 mL to 500 mL after the start of ECLA. Within 20 hours, the patient was weaned from ECLA, and extubation was possible 2 days later (Fig 1
). There were no hemorrhagic, pulmonary, or hematologic complications. The patient was discharged 15 days later.
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Fig 1. . Clinical course of extracorporeal lung assist (ECLA) for status asthmaticus. (AKBR = arterial ketone body ratio; PaCO2 = arterial carbon dioxide tension; PaO2 = arterial oxygen tension.)
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Comment
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It is estimated that the death rate from bronchial asthma in Japan is as high as 5.6 per 100,000 of the population [1]. There are approximately 6,000 asthma-related deaths in Japan per year. In the United States, the deaths due to asthma reached a nadir in 1977. Since that time, there has been a progressive increase with a current rate of approximately 1.7 per 100,000 of the population (4,000 asthma-related deaths per year) [2–4]. Increased mortality has also been reported in the United Kingdom, Australia, and New Zealand.
Bronchial asthma is not a major cause of death in Japan or the United States when compared with acute myocardial infarction or cancer. If the deaths are preventable, however, this is a serious public health concern.
The mainstays of therapy of status asthmaticus are medical (epinephrine, bronchodilators, and corticosteroid). Endotracheal intubation and positive-pressure ventilation are effective tools to correct hypoxemia and hypercapnea. Halothane and other inhalation agents have been described for use in severe cases because of their bronchodilatory effects. It is well known that long-term positive-pressure ventilation damages the lung, which may result in a permanent deterioration in pulmonary function.
In the 1970s, the outcome of the extracorporeal membrane oxygenation trial was disappointing for adult respiratory distress syndrome compared with the results in newborns. Gattinoni and associates [5] reported good clinical results with low-frequency positive-pressure ventilation with extracorporeal carbon dioxide removal in the 1980s. In the United States, ECLA recently has been used successfully in the treatment of patients with adult respiratory distress syndrome in whom conventional therapy has failed. Low-frequency positive-pressure ventilation with extracorporeal carbon dioxide removal is thought to prevent the pulmonary barotrauma and extrapulmonary derangements caused by conventional mechanical ventilation. With the recent improvements in femoral cannulas and percutaneous technique for emergency bypass, this method has become more practical for a variety of patients with cardiopulmonary insufficiency [6, 7].
We have employed emergent portable bypass in 35 patients with cardiopulmonary insufficiency. This is the first patient in whom venovenous bypass has been used at our institution in the treatment of status asthmaticus.
In patients who have suffered cardiopulmonary arrest due to status asthmaticus, we have employed percutaneous cardiopulmonary support as venoarterial bypass. As in the present case, when the patient is hemodynamically stable, venovenous bypass can provide preferable gas exchange for refractory respiratory failure [8].
The etiology of the immediate recovery from refractory wheezing and poor pulmonary compliance remains unclear. It is possible that the lung rest made it easier to clear secretions, which improved the compliance.
Extracorporeal lung assist may be used in patients in status asthmaticus to improve pulmonary function without the risk of pulmonary or extrapulmonary complications.
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Footnotes
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Address reprint requests to Dr Sakai, Department of Thoracic and Cardiovascular Surgery Saga Medical School, 5-1-1 Nabesima, Saga 849, Japan.
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References
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- Kataoka Y, Soma K, Ohwada T. Clinical evaluation for cardiopulmonary arrest due to bronchial asthma attack. JJAAM 1995;6:329–36.
- Jackson R, Sears M, Beaglehole R, Rea H. International trends in asthma mortality: 1970 to 1985. Chest 1988;94:914–8.
- Robin E. Risk-benefit analysis in chest medicine. Death from bronchial asthma. Chest 1988;93:614–8.[Abstract/Free Full Text]
- Robin E, Lewiston N. Unexpected, unexplained sudden death in young asthmatic subjects. Chest 1989;96:790–3.[Abstract/Free Full Text]
- Gattinoni L, Pesenti A, Mascheroni D, et al. Low frequency positive pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA 1986;256:881–5.[Abstract/Free Full Text]
- Phillips SJ, Ballentine BB, Slonine D, et al. Percutaneous initiation of cardiopulmonary bypass. Ann Thorac Surg 1983;36:223–5.[Abstract]
- Ohteki H, Suda H, Itoh T. Percutaneous cardiopulmonary bypass: experimental and preliminary clinical use. Artif Organs 1991;14:62–4.
- Shapiro MB, Kleaveland AC, Bartlett RH. Extracorporeal life support for status asthmaticus. Chest 1993;103:1651–4.[Abstract/Free Full Text]
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Abstract
Introduction
