Severe status asthmaticus: Prolonged treatment with assisted ventilation

Abstract

Three patients with progressively severe status asthmaticus which failed to respond to intensive medical therapy were treated successfully with prolonged assisted ventilation for 4, 5, and 7 days, respectively. The development of respiratory acidosis was the most reliable guideline indicating impending death and the need for a more aggressive therapeutic approach. The possible factors leading to this medical-resistant state included infection, fatigue, oversedation, insufficient medication, and overuse of sympathomimetic nebulized aerosols. The major problems encountered with prolonged assisted ventilation were: (1) Frequent monitoring of arterial blood gases was necessary in order to reliably assess the clinical state. (2) A volume-regulated ventilator, in these cases an Engstro¨m, was needed to supply adequate respiratory exchange. (3) Best results with the ventilator required cessation of voluntary respirations. This was most readily accomplished by the use of a curare-type muscle relaxant. (4) Tracheotomy was eventually needed to provide the best mode for continued bronchial lavage. (5) Potent bronchodilators, such as epinephrine and intravenous aminophylline, were ineffective despite normal arterial pH. With properly staffed and equipped respiratory intensive-care units and application of these diagnostic and therapeutic concepts, potential asthmatic deaths may be avoided.