(1519) An Absence of Flow: Severe Status Asthmaticus Requiring Venovenous ECMO and Aminophylline

Introduction: Status asthmaticus is a medical emergency characterized by severe bronchospasm, airway inflammation, and intraluminal mucous production resulting in progressive airway obstruction. Patients with asthma may develop an acute event that is unresponsive to standard treatment which may lead to respiratory failure and possible death. When failing standard therapies, alternative treatment considerations are needed.

Description: We present a 32 year-old male with a history of recurrent asthma exacerbations who presented to an outside institution with a 1 week history of progressive dyspnea, wheezing, and productive cough. Diagnosis of asthma exacerbation was made and initial treatment of IV corticosteroids, magnesium, and nebulized albuterol was started. The patient ultimately decompensated and required endotracheal intubation with a helium-oxygen gas mixture. Despite ventilator optimization, the patient continued to show hypercarbia and acidosis which prompted transfer to our facility for initiation of veno-venous ECMO (32 Fr Crescent Cannula, Medtronic). After initiation of V-V ECMO, the patient’s blood gas improved immediately. Ventilator settings continued to show low tidal volumes, prompting initiation of IV ketamine, nebulized epinephrine and epoprostenol with minimal improvement. On post-operative day 5, a 72 hour trial of aminophylline infusion was started with goal therapeutic concentration of 10-15 mcg/mL. With this treatment change, tidal volumes and respiratory mechanics rapidly improved. V-V ECMO was weaned and decannulated on post-operative day 8 and liberation from the ventilator occurred on post-operative day 10.

Discussion: In this case of status asthmaticus, the patient failed standard medical treatment. Despite V-V ECMO, the patient continued to display poor respiratory mechanics and hypoventilation. The addition of methylxanthine aminophylline rapidly abolished the bronchospasm which allowed weaning of V-V ECMO and liberation of the ventilator. While aminophylline is generally used in children, its use in adults, especially with refractory status asthmaticus resistant to other therapies, may be considered as an option.