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A5242 - Status Asthmaticus in Pregnancy Requiring Sevoflurane and ECMO
Author Block: B. Seth1, M. Gonzalez2, F. Schembri3; 1Internal Medicine, Boston University Medical Center, Boston, MA, United States, 2Department of Anesthesia, Boston University Medical Center, Boston, MA, United States, 3Pulmonary, Allergy, Sleep and Critical Care, Boston Univ Med Ctr, Boston, MA, United States.
Introduction
Status asthmaticus is a life-threatening condition characterized by progressive respiratory failure despite standard therapy. Observational data shows an association between poor asthma control and pregnancy, with resultant increased pregnancy-related risks. We report a case of a pregnant patient who presented with severe refractory status asthmaticus ultimately requiring inhaled sevoflurane and ECMO.
Case
A 32-year-old female at 23 weeks gestation (G2P1) was admitted dyspnea, wheezing, fever and myalgias and was diagnosed with an acute asthma exacerbation in the setting of Influenza B infection. She had childhood onset asthma, with multiple prior intubations, including during her prior pregnancy. On admission, she was tachypneic (RR 25-35) with accessory muscle use and diffuse biphasic wheezing. She was trialed on BPAP for 24 hours, but due to progressive hypercarbic respiratory failure was intubated. Over the next few hours, her respiratory compliance and gas-exchange deteriorated - no air movement was noted on auscultation, peak inspiratory pressure >50mmHg, tidal volume 100-110ml and gas-exchange worsened (pH 6.9, pCo2 >101mmHg). Continuous nebulized albuterol-ipratropium, IV methylprednisone, IV epinephrine, ketamine, and paralysis were attempted to improve her respiratory compliance, each to no avail. As arrangements were being made for ECMO, inhaled sevoflurane was initiated in the ICU with significant improvement in airway resistance, tidal volumes, peak inspiratory pressures, and acidosis. The patient was transferred to another facility where VV-ECMO was started with marked improvement, and 72 hours later she was extubated. No fetal distress was appreciated throughout her hospital course and she was ultimately discharged home, and had an uneventful delivery 3 months later.
Discussion
Asthma is one of the most common serious medical problems the occurs during pregnancy and pregnancy may alter maternal control of asthma. Status asthmaticus in pregnancy poses an especially complex situation, with considerable risk to both maternal and fetal outcomes. Anesthetic agents have bronchodilating effects, and few reports have described responses in patients with refractory status asthmaticus. Sevoflurane has been shown to reduce respiratory system resistance in non-asthmatic patients to a greater degree than halothane/isoflurane, though hypotension is a limiting factor. Reproductive studies have been performed in animal models and have revealed no evidence of harm to the fetus due to sevoflurane although there are no well controlled studies in pregnant women (Category B). More recently, ECMO has been used for adjunctive pulmonary support in life-threatening refractory status asthmaticus. We describe a case and review the literature where both these interventions resulted in improved outcomes.