Abstract
Background:
Life threatening refractory asthma requiring intubation and mechanical ventilation is often associated with a high incidence of ventilator induced trauma (VILI) and has a mortality rate of around eight percent. Often these patients present with high level of arterial PaCO2 which require both a high minute ventilation and airway pressures despite lung protective ventilation and the administration of Heliox gas mixture. These ventilator requirements place this patient population at risk for excessive auto-PEEP and barotrauma. Another approach to meet gas exchange goals and to provide maximum lung protective is to place these patients on venous-venous extracorporeal oxygenation membrane (ECMO) support. The clinical rational for this management would be to protect the lung from any additional VILI and provide a stable level of ventilation and acid-base balance.
Methods:
During a two year time frame we placed six status asthmaticus patients with refractory gas exchange on V-V ECMO. Five of the six patients were management on V-V ECMO until the asthma exacerbation was stabilized and progressed to both ECMO and ventilator liberation. One patient expired secondary to multi-system organ failure unrelated to asthma. All patients were ventilated via pressure or volume target modes to achieve an exhaled tidal volume between 4-5cc/kg/IBW and PEEP was set via either a pressure/volume tool or via transpulmonary monitoring. ECMO parameters we set to achieve a SpO2>88% and a PH>7. 25.
Results:
There was no additional occurrences of additional VILI post ECMO intervention. And all patients receive pharmacological paralytics, Heliox, and continuous beta-agonist therapy for the first forty hours of mechanical ventilation and ECMO support. (Table 1)
Conclusions:
Based on our clinical experiences, V-V ECMO along with lung protective ventilation can provide a safe management of the status asthmaticus with refractory gas exchange.
All pts. received continuous beta-agonist delivery PEEP setting were guided by transpulmonary E View all access options for this article.V-V ECMO for Life threatening asthma
Patient #
Age/G
Vent Mode/TV setting
V-V ECMO LOS
ECMO FIO2/Flow
Ext ubation time from cannulation
Heliox
Survival
1
51/M
PCMV4cc/kg/IBW
7
100%/5lpm
120 hrs.
Yes
Yes
2
28/M
CMV4cc/kg/IBW
8
100%/9 lpm
70 hrs.
Yes
Yes
3
49/M
PCMV 5cc/kg/IBW
5
100%/4.5 lpm
42 hrs.
Yes
Yes
4
31/F
PCMV5cc/kg/IBW
15
80%/ 3lpm
NA
Yes
No
5
18/M
CMV4cc/kg/IBW
8
80%/4 lpm
209 hrs.
Yes
Yes
6
31/F
PCMV4cc/kg/IBW
9
100/1.5 lpm
52 hrs.
Yes
Yes
Get full access to this article