Extracorporeal membrane oxygenation (ECMO) for near fatal asthma refractory to conventional ventilation

INTRODUCTION: Approximately 2-4% of all patients hospitalized for acute asthma require invasive mechanical ventilation. 7% of these will not survive (Krishnan, V. et al. Am J Respir Crit Care Med 2006; 174:633). We describe a case of near fatal Asthma who survived successfully by the initiation of ECMO. CASE PRESENTATION: A 29-year-old female, known asthmatic on steroid inhalers, inhaled/nebulised bronchodilators, long term Prednisolone, Theophylline and Montelukast presented with acute shortness of breath. Following initial treatment with nebulised bronchodilators and Magnesium Sulphate, there was rapid deterioration requiring intubation and mechanical ventilation. Severe bronchospasm ensued following mechanical ventilation. Peak airways pressures remained at 55cm H2O with intrinsic PEEP of 14. Despite treatment with sedation, paralysis, IV salbutamol and inhaled sevoflurane, her condition deteriorated so she was transferred for ECMO. Whilst on ECMO her CO 2 normalised within 48 hours. She was extubated within 72 hours of initiating ECMO and was discharged to the ward next day. CONCLUSION: ECMO should be considered sooner for status asthmatics not responding to maximal pharmacological therapy and ventilatory support to prevent ongoing lung injury and mortality.