Abstract
Status asthmaticus respiratory failure is associated with thickened mucus secretions necessitating aggressive pulmonary clearance. The role of bronchoscopy in pediatric mechanically ventilated asthmatic patients has not been published. A chart review was performed on all pediatric intensive care unit (PICU) asthmatics with respiratory failure over 13 years. Forty-four patients were identified. Patients were managed per standardized guidelines for status asthmaticus with mechanical ventilation. Ventilator management prioritized spontaneous breathing with pressure support. Extubation criteria included spontaneous tidal volumes of 5-7 cm(3) /kg on low-pressure support. Standard endotracheal tube pulmonary toilet were implemented. Twenty-nine patients underwent bronchoscopy as an adjunctive therapy. Indications for bronchoscopy included: Pathogen identification via bronchoalveolar ravage, atelectasis, mucus obstruction resulting in severe air trapping, suspected aspiration, and poor response to standard therapy. Clinical outcomes of this intervention were compared to the fifteen patient cohort who did not undergo bronchoscopy. Bronchoscopies revealed thick mucus plugs, secretions, and bronchial casts. The large airways were lavaged for clearance of obstructive secretions with normal saline. All patients tolerated the procedure without any complications. Demonstrable improvement in pulmonary compliance was noted. The median time of intubation for the bronchoscopy group was 10 hr compared to 20.5 hr for the control group (P < 0.0005). The mean intensive care unit length of stay was 3.06 days for the bronchoscopy group versus 3.4 days for the non-bronchoscopy group (P < 0.05). Flexible bronchoscopy with bronchial lavage is a safe adjunctive therapy in pediatric asthmatics with respiratory failure resulting in reduced mechanical ventilation and intensive care length of stay. Restoring lung volume in certain asthmatics during respiratory failure may be deemed beneficial. Further validated studies are necessary to recommend bronchoscopy to the present, accepted treatment regimen in pediatric asthmatic respiratory failure.
Highlights
Data were collected on 44 status asthmaticus children who met the primary criteria of respiratory failure requiring intubation and mechanical ventilation
Mortality of acute severe respiratory failure related asthma episodes are associated with lung consolidation, atelectasis, or severe mechanical airway obstruction leading to severe hypoxia/hypoxemia
Our study shows bronchoscopy to be a safe modality in the management of intubated patients with status asthmaticus
Summary
Asthma remains a prevalent pediatric condition with associated morbidity and mortality despite modern therapeutic modalities.[1,2] A subpopulation of severe asthma suffers respiratory failure with 2% mortality.[2,3] Severe air flow limitation leads to ventilation/perfusion (V/Q) imbalance, progressive alveolar hypoxia, hypoxemia, CO2 retention, respiratory failure, and subsequent death.[4,5,6,7,8] The presence of infection, atelectasis, or severe mucous plugging may contribute to mechanical air flow obstruction, segmental lung collapse, lung consolidation, and increased inflammation.[9,10,11,12,13,14]. Several reports in the adult population elucidated the role of bronchoscopy in patients with severe asthma.[15,16,17,18] The safety and efficacy of flexible fiberoptic bronchoscopy in children with asthma and respiratory failure have not been established. The purpose of our study was to evaluate the safety, efficacy, and clinical ß 2012 Wiley Periodicals, Inc
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