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Case reports
Rescue of acute refractory hypercapnia
and acidosis secondary to life-threatening
asthma with extracorporeal carbon
dioxide removal (ECCO R)
We report a case of life-threatening asthma associated with profound hypercapnia and acidosis that was refractory to conventional medical therapy but was managed successfully using an extracorporeal carbon dioxide removal (ECCO R) device (NovaLung iLA®). In the UK, ECCO R is still not widely available, with few intensivists and anaesthetists having experience of its use in routine intensive care unit practice. Extracorporeal CO removal may have a role in the management of acute life-threatening asthma and in preventing patient death and improving overall outcomes.
Keywords: life-threatening; asthma; extracorporeal carbon dioxide removal (ECCO2R); Novalung; ECMO Case report
Rapid sequence induction was undertaken using ketamine (2 mg/kg), fentanyl (2 µg/kg) and rocuronium (1.2 mg/kg). She A 40-year-old female with known asthma presented to the had never had a general anaesthetic before and although the emergency department at James Cook University Hospitalcomplaining of increasing chest tightness and shortness of risk was small, the possibility of allergy to the egg protein in breath. She had a family history of malignant hyperpyrexia propofol was too great to consider its use. Midazolam and (MH), proven on muscle biopsy, and anaphylaxis to eggs. She ketamine were used for maintenance of anaesthesia. Central had been admitted to the high dependency unit earlier in the venous access was achieved. Intravenous aminophylline, year with an exacerbation of asthma, which had resolved with salbutamol and magnesium were continued. Pressure medical management. On this occasion, she had no relief from controlled ventilation was undertaken with a rate of 16 breaths use of home nebulisers. On admission, the patient was per minute, inspiratory pressure 28 cm H2O with no positive conscious, with a respiratory rate of 29 breaths per minute, end-expiratory pressure (PEEP) initially and with an inspiratory-expiratory (I:E) ratio of 1:3; with these settings, face mask. Auscultation revealed reduced air entry bilaterally with widespread wheeze. Her heart rate was 143 beats per One hour later, ventilation was progressively worse due to minute and blood pressure 136/82 mm Hg.
deteriorating lung compliance. Peak inspiratory pressures Her initial arterial blood gases on 80% O volumes of just 300 mL (3.75 mL/kg). Intrinsic PEEP 2 4.45 kPa, pO2 24.5 kPa, BE -4.5 mmol/L. Chest X-ray was suggestive of concurrent right mid and lower zone measured 13 cm H2O. Sedation was increased and rocuronium pneumonia complicating her acute asthma. She was treated boluses, followed by an infusion, administered. Further with nebulised salbutamol and ipratropium, IV hydrocortisone, ventilatory manoeuvres were undertaken: the I:E ratio was aminophylline infusion, magnesium sulphate boluses, co- extended to 1:4-5, PEEP was added (3 cm H2O), ventilator amoxiclav and clarithromycin, and admitted to the high frequency was reduced to 9/minute. A bronchoscopy was dependency unit. Four hours later, her condition deteriorated performed, but no secretions were evident. Widespread wheeze and the arterial blood gases showed pH 7.23, pCO was now much worse on auscultation. An adrenaline infusion was started. Inhalational anaesthetic agents were 2 29.2 kPa, BE -2.1 mmol/L on 100% oxygen. Non-invasive ventilation using a BIPAP hood was attempted; however, this contraindicated because of the history of MH. Conventional was poorly tolerated and the patient was transferred to the therapeutic strategies had failed; on 60% oxygen, her pCO2 ICU. On the ICU, non-invasive ventilation was continued was now 13.5 kPa, with pH 7.07 and pO2 22 kPa. In addition, intermittently, but poor compliance and increasing fatigue with because of her worsening hypercapnia and acidosis secondary worsening acidosis and hypercapnia led to the decision to to poor lung compliance, the patient was becoming intubate and mechanically ventilate the patient in an attempt Instititution of extracorporeal membrane oxygenation Case reports
(ECMO) life support was considered; however, despite having iLA membrane does not improve oxygenation significantly; a cardiothoracic centre at James Cook Hospital, extra-corporeal severe asthma complicated by both hypoxia and hypercapnia devices had never been used. We discussed the case with the needs to be treated with an ECMO device (ie providing both cardiothoracic team at Freeman Hospital in Newcastle-upon- oxygenation and CO2 removal by the membrane device) or an Tyne who, because of the patient’s unstable clinical state, sent a iLA membrane in combination with ventilatory strategies, such surgical team to the James Cook Hospital to site a femoral as high-frequency oscillatory ventilation, as proposed in arterio-venous carbon dioxide removal device (ECCO2R) In most cases of acute life-threatening asthma, oxygenation The beneficial effects of the NovaLung iLA® were is usually maintained.8,13 However, the significant hypercapnia immediate. Carbon dioxide levels fell from 14 kPa to 6.4 kPa in and acidosis that ensues secondary to poor lung compliance 45 minutes, with resolution of acidaemia and the patient was and gas trapping causes considerable morbidity and mortality.
more stable haemodynamically. Average blood flow through the In addition to removing CO2 and improving acidosis, the iLA iLA was 1.5 L/min, with oxygen sweep gas flow rate set also allows lung protective ventilatory strategies to be initially at 6 L/minute, increasing to a maximum of employed, as the need for high tidal volumes and inspiratory10 L/minute. Protective lung ventilation was continued, with pressures to remove CO2 is reduced. This reduces the risk of low tidal volumes (3-4 mL/kg) which maintained the pO2 more associated acute lung injury. With the hypercapnia and acidosis than 8 kPa, with peak inspiratory pressures no higher than corrected, using ECCO2R allows time for conventional 30 cm H20 and carbon dioxide removal via the iLA. intensive care management to work and the bronchospasm to Full conventional medical therapy for bronchospasm was resolve. With time and patient improvement, the iLA can then continued, with iLA and lung protective ventilation strategy for a further four days, until the lung compliance improved and Complications associated with the iLA include the bronchospasm reversed. Klebsiella pneumoniae was isolated haemorrhage, vascular damage, ischaemia of the limbs and from sputum samples. The NovaLung iLA® was removed in complications associated with heparinisation. Absolute theatre on day four. A percutaneous tracheostomy was contraindications to iLA include heparin-induced performed to aid weaning from the ventilator at day six. The thrombocytopenia and cardiogenic shock. Advanced occlusive patient was discharged from the critical care unit to the ward peripheral vascular disease is a relative contra-indication.15 on day 13 and deemed fit for hospital discharge 16 days after A recent telephone survey of ten intensive care units within the Northern region on one day has shown that only one unit The introduction of the NovaLung iLA® prevented patient uses Novalung iLa® regularly for lung transplant or respiratory deterioration and death in this case, allowing time for a failure patients (Freeman Cardiothoracic). Three other units protective lung ventilation strategy to be maintained with (Freeman, Wansbeck, James Cook) within the region have conventional medical therapy until severe bronchospasm used NovaLung iLa® once in life-threatening asthma, with one other unit (North Tyneside) referring a patient with respiratoryfailure to Leicester for ECMO in the last six months.
Discussion
Generally, most clinicians within the Northern region are aware Since 1981, there has been a small number of case reports of of extracoroporeal life support techniques, particularly after the ECMO use in the treatment of life-threatening asthma, with recent H1N1 surge, although specific knowledge of ECCO2R significant improvements observed and reduction in case devices was limited. All would consider this technique in life- Recently, with advances in extracorporeal life threatening asthma if there was increased availability of devices. Some units expressed concern over associated vascular with improved availability and application to all areas.10,11 complications. Generally, within the Northern region at least, interventional Lung Assist® (iLA), in adult life-threateningasthma was reported with prevention of death and eventual Conclusion
recovery.12 Since then, further case reports, including the case Despite a growing number of case reports of success in the presented here, have reinforced the important role that treatment of life-threatening asthma, ECCO2R is still not ECCO2R can play in life-threatening asthma that is refractory widely available throughout the UK, with only specialist to conventional treatment strategies.11, 13 centres having such resources. As a result, experience of such The NovaLung iLA membrane ventilator® is a type of ECCO2R techniques, such as the NovaLung iLA® is limited, ECCO2R.11 The principle aim of the iLA is to improve with many anaesthetists/intensivists having little or no respiratory failure that is complicated by hypercapnia and acidosis. The patient’s blood is circulated through the We have shown that the Novalung iLA® system can be used extracorporeal membrane via two cannulae, one sited in the safely and effectively without prior experience of the device femoral artery of one leg, the other in the femoral vein of the (although this is not advised), and feel that increased other leg, using a pump or the patient’s own cardiac output awareness of the value of ECCO2R as a rescue technique in life-threatening asthma refractory to conventional therapy The iLA membrane allows quick and efficient removal of could save lives. With increased use and availability, carbon dioxide and thus reversal of respiratory acidosis. The extracorporeal techniques may help reduce the static mortality Case reports
rate in asthma, which on average still accounts for over 1,300 8. Tewari A, Ali T, Baba R. Case of successful extracorporeal life support
(ECLS) in a patient with refratory asthma – importance of increasing This begs the question of whether a formal randomised awareness of the role of ECLS in the UK. Internet J Healthcare Admin2009;6. http://www.ispub.com/journal/the_internet_journal_of_ controlled multicentre trial of ECCO2R use in asthma is healthcare_administration/volume_6_number_2_30/article/case-of- warranted or feasible. If effective, should regional units with successful-extracorporeal-life-support-ecls-in-a-patient-with-refractory- ECCO2R devices provide a rescue service to district general asthma-importance-of-increasing-awareness-of-the-role-of-ecls-in-the- hospitals in their region, and would this be a cost-effective measure overall for an expensive and limited resource? 9. Hebbar KP, Petrillo-Albarano T, Coto-Puckett W et al. Experience with
In the future, improvements in vascular access techniques use of extracorporeal life support for severe refractory status astmaticus in children. Crit Care 2009;13:R29.
10.Napolitano L, Park PK, Raghavendran K, Bartlett RH. Nonventilatory
associated complications. Also, on the horizon, NovaLung are strategies for patients with life threatening 2009 H1N1 influenza and due to produce a venovenous iLA (iLa activve®) device, which severe respiratory failure. Crit Care Med 2010;38:e74-e90.
it is hoped will provide a bedside CO2 removal and 11.Novalung: Compendium of evidence 5.0. iLA membrane ventilator/
oxygenation device combined.11 Results are awaited. Vision alpha HFOV/Mechanical Ventilation. http://www.novalung.com
Accessed February 2011.
Acknowledgement
12.Elliot S, Paramasivam K, Oram, J et al. Pumpless extracorporeal carbon
dioxide removal for life-threatening asthma. Crit Care Med 2007;35: We are grateful to Mr Tokowich, Dr Searle and the team at Freeman Hospital in Newcastle upon Tyne for their help and 13.Coleman NE, Dalton H. Extracorporeal life support for status
support in providing a NovaLung iLA® during this case.
asthmaticus: the breath of life that's often forgotten. Crit Care 2009;13:136.
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