A case of near-fatal asthma precipitated by H1N1 pneumonia with critical PCO2 successfully treated by multipharmacological approach

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We describe a case of prolonged severe hypercapnia with respiratory acidosis occurring during an episode of near-fatal asthma in a 15-year-old boy, followed by complete recovery. After admission to the ICU, despite treatment with maximal conventional bronchodilatation therapy, the clinical picture deteriorated with evident signs of respiratory muscle fatigue. The patient was sedated, intubated, and mechanically ventilated. At 30 min after admission, arterial PCO2 reached 132 mmHg, pH was 6.94, and PO2 was 95 mmHg, and then the measurements repeated after 30 min revealed pH of 6.80, PCO2 of 209 mmHg, and PO2 of 73 mmHg. Oxygenation was initially hypoxic but rapidly maintained, and successful recovery followed without neurological or cardiovascular sequelae. This case shows the cardiovascular and neurological tolerance of a prolonged period of supercarbia in a young patient. The most important lesson to be learned is the extreme importance of maintaining adequate tissue perfusion and oxygenation during an asthma attack. The second lesson is that when conventional bronchodilators fail, the intensivist may resort to the use of drugs such as ketamine, magnesium sulfate, and inhalation anesthesia. In this context, deep sedation and curarization are important, not only to improve oxygenation but also to reduce cerebral metabolic requirements.