(P103) Refractory Status Asthmaticus Managed with Sevoflurane

Chief Complaint : A 38-year-old female with a history of asthma, tobacco and marijuana smoking, obesity, and hypertension presented with worsening dyspnea, chest tightness and rhinorrhea.

History of Present Illness : She was admitted to the ED with the aforementioned complaints, stating that her symptoms at home did not abate with ipratropium-albuterol treatments. In the ED she was managed with oxygen, nebulized ipratropium-albuterol, IV methylprednisolone, IV magnesium, and IV theophylline without improvement and subsequent deterioration. She was admitted to the medical intensive care unit (ICU) and required intubation/mechanical ventilation on volume cycled assist control. She was sedated with propofol and midazolam and briefly with ketamine. Her high airway pressures (up to 55 cmH2O) and small tidal volumes eventually necessitated pressure control ventilation with cis-atracurium paralysis. ABGs worsened to pH < 7 and pCO2 > 125 mmHg. Her SpO2 remained quite variable, and her PaO2 continued to decrease over a 6-hour period, necessitating 100% FiO2 and 12 cmH2O of peep. Anesthesiology was consulted for management with inhaled anesthetics to correct her ventilation and waning ability to oxygenate effectively.

Pertinent Physical Exam: There were loud wheezes bilaterally on admission to the ED that progressed to extremely diminished breath sounds over several hours. Breathing was demonstrably paradoxical. CXR revealed some focal atelectasis and hyperinflation. EKG demonstrated heart rates of 100-125/ min. The patient was also hypertensive up to 180/100 mmHg. SpO2 readings varied between 85%-95%.

Pertinent Laboratory Data: See Table 1.

Case Discussion: The patient was taken to an operating room (OR) and started on 1.5-2.0% sevoflurane. Within 30 minutes of sevoflurane administration expiratory wheezes were again audible, and within 90 minutes of therapy normal tidal volumes were achieved with near-normal peak pressures with a steady improvement of blood gases (see Table 1). She was transferred back to the ICU where she continued to improve, demonstrating adequate oxygenation and ventilation. Her pH/pCO2 completely normalized within 12 hours of the OR administration of sevoflurane. Paralytics were weaned off on the third day post admission day. She extubated on the ninth post admission day, and was discharged 15 days after presentation.

Asthma is characterized by chronic inflammation, airway hyper-responsiveness, bronchospasm, and reversible airway obstruction. Status asthmatics is a severe form of asthma that involves hypoxemia, hypercarbia, and respiratory failure, typically refractory to standard therapeutic measures. It is an emergency condition. This case demonstrates that patients in status asthmaticus can be managed with inhaled anesthetics (which are bronchodilators) in reducing bronchospasm, improving ventilation, and accelerating recovery. While no current guidelines exist regarding the ideal anesthetic agent and its dosing in status asthmaticus, there have been published reports describing their successful use, particularly with sevoflurane and isoflurane. Desflurane, on the other hand, at particularly at high concentrations, may increase smooth muscle tone and airway resistance and is not recommended in patients with asthma. More formal studies would be useful to establish guidelines and methods for the use of inhaled anesthetic agents in patients with refractory status asthmaticus.

References and Acknowledgements (Optional): CDC. Most Recent National Asthma Data—cdc.gov/asthma/most_recent_national_asthma_data.htm. February 9, 2023.
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