Volatile anaesthetic for treatment of respiratory failure from status asthmaticus requiring extracorporeal membrane oxygenation

Abstract

A 37-year-old male smoker with asthma presented with status asthmaticus refractory to terbutaline, intravenous magnesium, continuous bronchodilators, steroids, heliox and theophylline infusion. He was intubated on hospital day 2 and cannulated for veno-venous extracorporeal membrane oxygenation (V-V ECMO) on hospital day 3 for refractory respiratory acidosis secondary to hypercapnia and hypoxemia despite maximum medical management over 4 days. He was started on inhaled isoflurane with improvement in peak airway pressures and respiratory acidosis, allowing for prompt weaning from V-V ECMO and extubation. Inhaled volatile anaesthetics exert a direct action on bronchiole smooth muscle causing relaxation with significant effect despite severely impaired pulmonary function. This treatment in patients on ECMO may allow for earlier decannulation and decreased risk of coagulopathy, ECMO circuit failure, infection, renal failure, pulmonary haemorrhage and central nervous system haemorrhage. However, major limitations exist in delivering volatile anaesthetics, which may make use inefficient and costly despite efficacy.

Case report: Isoflurane therapy in a case of status asthmaticus requiring extracorporeal membrane oxygenation

“…Volatile anesthetics cause relaxation through direct action on bronchiole smooth muscle and through systemic uptake ( 19 ). They have also shown immune modulatory and anti-inflammatory actions ( 26 ).…”

“…There are multiple postulated mechanisms regarding how these agents work, including direct relaxation of bronchial smooth muscle, inhibition of the release of inflammatory mediators, beta adrenergic receptor stimulation, reduction of vagal tone and vagal-mediated reflexes and antagonism of the effects of histamine and methacholine (19)(20)(21). The use of inhaled anesthetics in patients requiring ECMO has been reported more recently, both in severe refractory SA and acute respiratory distress syndrome (ARDS) (19,22); however, the literature is limited. In previously reported cases of utilization of inhaled volatile anesthetics for severe SA, the anesthetics were delivered via the inhalational route utilizing an anesthesia ventilator (19,23).…”

“…Inhaled volatile anesthetics have been cited as a rescue therapy for severe refractory status asthmaticus ( 15 – 18 ). There are multiple postulated mechanisms regarding how these agents work, including direct relaxation of bronchial smooth muscle, inhibition of the release of inflammatory mediators, beta adrenergic receptor stimulation, reduction of vagal tone and vagal-mediated reflexes and antagonism of the effects of histamine and methacholine ( 19 – 21 ). The use of inhaled anesthetics in patients requiring ECMO has been reported more recently, both in severe refractory SA and acute respiratory distress syndrome (ARDS) ( 19 , 22 ); however, the literature is limited.…”

“…The use of inhaled anesthetics in patients requiring ECMO has been reported more recently, both in severe refractory SA and acute respiratory distress syndrome (ARDS) ( 19 , 22 ); however, the literature is limited. In previously reported cases of utilization of inhaled volatile anesthetics for severe SA, the anesthetics were delivered via the inhalational route utilizing an anesthesia ventilator ( 19 , 23 ). In the case presented here, isoflurane was administered systemically via the ECMO circuit.…”

High-Frequency Ventilation in the Treatment of Acute Respiratory Failure

“…До настоящего времени идут поиски максимально эффективной и безопасной терапии лечения рефрактерного астматического статуса. Терапия включает применение миорелаксантов, гелия [75], общую анестезию севофлураном [76], ЭКМО [77][78][79]. Выбор режима ИВЛ остается дискутируемым вопросом.…”