Extracorporeal membrane oxygenation (ECMO) and beyond in near fatal asthma: A comprehensive review

High-frequency percussive ventilation as a lifesaving intervention in a pediatric case of life-threatening asthma: a case report and literature review

INTRODUCTION

Severe acute asthma exacerbation requiring mechanical ventilation, referred to as life-threatening asthma, presents significant challenges due to elevated airway resistance, dynamic hyperinflation, and impaired gas exchange. Conventional mechanical ventilation may be insufficient in these cases, necessitating alternative strategies. High-frequency percussive ventilation (HFPV) offers a promising approach by combining improved oxygenation and ventilation with effective secretion clearance.

CASE STUDY

An 11-year-old male with a history of asthma and eczema presented to the emergency department in respiratory failure with profound hypercarbia. Life-threatening asthma with cardiopulmonary arrest led to endotracheal intubation and initiation of mechanical ventilation. Despite the use of conventional settings, oxygen saturation remained critically low, and air trapping persisted. The patient was transitioned to HFPV via a VDR®-4 ventilator.

RESULTS

Arterial blood gases demonstrated rapid improvement within 2 hours (from pH 6.7, pCO2 >120 mmHg to pH 7.169, pCO2 77.2 mmHg). After 29 hours on HFPV, the patient was transitioned to conventional ventilation, followed by tracheal extubation to high-flow nasal cannula. The patient was discharged home within 72 hours with optimized asthma management.

CONCLUSION

This case demonstrates the potential efficacy of HFPV in managing life-threatening pediatric asthma, achieving rapid stabilization without the use of neuromuscular blockade. Further prospective studies are needed to evaluate HFPV's potential as a rescue therapy in both specialized and non-specialized settings.

Management of Asthma and COPD Exacerbations in Adults in the ICU

Severe, life-threatening asthma and COPD exacerbations are managed commonly in the ICU and are associated with significant morbidity and mortality. It is important to understand the commonalities and differences in the diagnosis and management of these obstructive lung diseases to improve patient outcomes via evidence-based care. In this review, we first outline triggers of acute asthma and COPD exacerbations and an initial diagnostic evaluation and severity assessment. We then review the pathophysiologic features of asthma and COPD exacerbations and create a framework for the management of exacerbations in critically ill adult patients aimed at reducing airway inflammation, reversing bronchospasm, and, in severe cases, supporting patients with mechanical ventilation or advanced therapies until clinical improvement is achieved.

Rapidly progressive mucus plugs in allergic bronchopulmonary mycosis

INTRODUCTION

Allergic bronchopulmonary mycosis (ABPM) is a chronic airway disease characterized by the presence of fungi that trigger allergic reactions and airway obstruction. Here, we present a unique case of ABPM in which a patient experienced sudden respiratory failure due to mucus plug-induced airway obstruction. The patient's life was saved by venovenous extracorporeal membrane oxygenation (VV-ECMO) and bronchoscopic removal of the plug. This case emphasizes the clinical significance of mucus plug-induced airway obstruction in the differential diagnosis of respiratory failure in patients with ABPM.

CASE STUDY

A 52-year-old female clerical worker with no smoking history, presented with dyspnea. CT scan revealed mucus plugs in both lungs. Despite treatment, the dyspnea progressed rapidly to respiratory failure, leading to VV-ECMO placement.

RESULTS

CT revealed bronchial wall thickening, obstruction, and extensive atelectasis. Bronchoscopy revealed extensive mucus plugs that were successfully removed within two days. The patient's respiratory status significantly improved. Follow-up CT revealed no recurrence. Fungal cultures identified Schizophyllum commune, confirming ABPM. Histological examination of the mucus plugs revealed aggregated eosinophils, eosinophil granules, and Charcot-Leyden crystals. Galectin-10 and major basic protein (MBP) staining supported these findings. Eosinophil extracellular traps (EETs) and eosinophil cell death (ETosis), which contribute to mucus plug formation, were identified by citrullinated histone H3 staining.

CONCLUSION

Differentiating between asthma exacerbation and mucus plug-induced airway obstruction in patients with ABPM and those with acute respiratory failure is challenging. Prompt evaluation of mucous plugs and atelectasis using CT and timely decision to introduce ECMO and bronchoscopic mucous plug removal are required.

Near fatal asthma in a case of allergic bronchopulmonary aspergillosis (ABPA) treated with ECMO

BACKGROUND

Fatal asthma is a rapidly progressing and highly fatal form of asthma. Mechanical ventilation, although necessary for respiratory support, can exacerbate the condition and lead to ventilator-associated lung injury. ECMO therapy is crucial in allowing the lungs to rest and recover, as it provides extracorporeal membrane oxygenation.

CASE PRESENTATION

A 40-year-old man presented with dyspnea following a mountain climb, which rapidly worsened, leading to respiratory failure and loss of consciousness. Despite drug therapy and mechanical ventilation, arterial blood gas analysis showed persistent hypercapnia. After 3 days of ECMO support, the patient was successfully extubated and underwent treatment for Aspergillus infection. Chest CT returned to normal after 3 months of anti-aspergillus therapy.

CONCLUSION

When drug therapy and mechanical ventilation fail to improve respiratory failure in fatal asthma, prompt initiation of ECMO support is essential to create opportunities for subsequent etiological treatment.