The management of respiratory failure in childhood status asthmaticus. Experience with 30 episodes and evolution of a technique

Abstract

The allergy and anesthesiology services of Children's Hospital of Philadelphia have, since 1961, managed 22 children in 30 episodes of status asthmaticus severe enough to need ventilatory assistance. The technique evolved with experience, starting with tracheal intubation followed by (1) general anesthesia and manual ventilation, 4 episodes; (2) mechanically assisted ventilation with a pressure-flow cycled ventilator (Bird Mark VIII) under heavy sedation, 7 episodes; (3) controlled mechanical ventilation (Bird Mark VIII) with d-tubocurarine and light sedation, 11 episodes; (4) controlled ventilation starting with a Bird Mark VIII and changing to a volume-cycled ventilator (Emerson), 3 episodes; and currently (5) controlled ventilation with the Emerson under light sedation and d-tubocurarine, 5 episodes. The criteria for respiratory failure in children with status asthmaticus are presented. Adjunctive therapy has included intravenous fluids with sodium bicarbonate, antibiotics, bronchodilators, corticosteroids, and vigorous chest physiotherapy, followed by sterile endobronchial aspiration. Currently we monitor ECG and directly transduced central venous and peripheral arterial prcssure displayed on an oscilloscope. Arterial pH, P co 2 , base excess, and P o 2 are determined frequently, and there is continuous clinical observation in the intensive care unit. There have been 18 complications, including one death. Every patient was amnesic for the period of assisted ventilation. The technique is an effective method of supporting life in children in respiratory failure caused by status asthmaticus until the attack subsides. A trained team, constantly available, is necessary.