SHM Converge Scientific Abstract ePoster Gallery-Severe Hypercapnic Respiratory Failure in Status Asthmaticus With Extreme Ventilator Pressures and Persistent Bronchospasm: A Case Requiring Ecmo-Level Evaluation

Severe Hypercapnic Respiratory Failure in Status Asthmaticus With Extreme Ventilator Pressures and Persistent Bronchospasm: A Case Requiring Ecmo-Level Evaluation

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This case describes a 22-year-old woman with severe persistent asthma and a history of prior ICU admissions and intubation who developed near-fatal status asthmaticus after a viral upper respiratory infection. She arrived to the emergency department with rapidly worsening dyspnea, wheezing, dry cough, rhinorrhea, tachycardia, and hypoxemia. A respiratory viral panel was positive for rhinovirus/enterovirus.<br /><br />Her respiratory failure progressed to severe hypercapnic acidosis, with arterial pH falling as low as 6.94–6.97 and pCO2 rising to 124 mmHg, indicating impending respiratory arrest and hypercapnic encephalopathy. She required emergent intubation because of declining mental status and failure of inhaled therapy. Imaging repeatedly showed no pneumonia, pneumothorax, or other parenchymal lung disease, confirming obstructive physiology as the cause.<br /><br />Despite maximal conventional therapy, including continuous bronchodilators, ipratropium, high-dose intravenous steroids, magnesium, terbutaline, theophylline, epinephrine, Heliox, deep sedation, and continuous neuromuscular blockade, she remained severely obstructed. Ventilation was extremely difficult, with peak pressures often above 50–60 cm H2O, plateau pressures in the 30s, and persistent auto-PEEP and dynamic hyperinflation. Blood gases improved only partially and remained unstable.<br /><br />Her course was further complicated by tachycardia, intermittent hypotension requiring vasopressors, lactic acidosis, electrolyte abnormalities, and transient anisocoria, which later had a negative head CT and was felt to be medication-related or due to hypercapnia. Because of persistent hypercapnia and failure of conventional management, the ICU team initiated early ECMO evaluation and transferred her to an ECMO-capable tertiary center for possible venovenous ECMO.<br /><br />Overall, this case highlights the life-threatening severity of fulminant status asthmaticus, the limitations of standard ventilatory and medical treatment, and the importance of early escalation to ECMO in refractory cases.

Asset Subtitle

Rawan Antar

Meta Tag

Author List Akram Taha, Alexander A. Restum, Michael Nunu, Rawan Antar, Sara Komaiha

Category Clinical Vignettes

Concept Status Asthmaticus

Concept Bronchospasm

Concept Respiratory Failure

Concept Chronic CO2 Retention

Concept Altered Mental Status

Distinguished Non-Finalist

Presenter Organization Wayne State School of Medicine

Presenting Author Rawan Antar

Track Adult

Keywords

status asthmaticus

severe asthma

hypercapnic respiratory failure

rhinovirus infection

endotracheal intubation

dynamic hyperinflation

auto-PEEP

bronchodilator therapy

venovenous ECMO

ICU admission

Status Asthmaticus

Bronchospasm

Respiratory Failure

Chronic CO2 Retention

Altered Mental Status