Community Coordinated Care in the Use of Isoflurane Augmented Mechanical Ventilation Treatment for Life Threatening Asthma

Cox, Timothy, RRT, Nadkarni, Vinay, MD, Cullen, Edward, MD, Christie, John, RRT; Resnik, Patty RRT, Grillo, Angelo MD, Muirhead, Karen RRT A.I. DuPont Hospital for Children, Thomas Jefferson Medical College, Christiana Care Health System, Wilmington, De

Introduction: Major complications from positive-pressure breathing in asthmatic patients are common. Bronchodilatory effects of inhalational anesthetic agents, such as Isoflurane, have long been observed by anesthesiologists. The timely use of general anesthesia to support conventional medical and ventilatory care has been reported useful for bronchodilation and facilitating a rapid wean from the ventilator. We report a case of a pediatric patient, status post respiratory arrest secondary to status asthmaticus, treated with mechanical ventilation and isoflurane. Case Summary: TF, 14 year old, 70 kg adolescent, never previously hospitalized, had a history of moderate-severe asthma as a child. He awoke from sleep, at approximately 0250, with sudden shortness of breath. stopped breathing and required CPR by family members for approximately 1minute. Upon Medic arrival, his Oxygen saturation by Pulse Oximeter was 50%. He was manually ventilated via ETT and transported to our affiliate tertiary hospital's (CCHS) ER, where he was managed with an epinephrine infusion and placed on mechanical ventilation. ER Course: A consulting pediatric intensivist, from our institution met the patient in the emergency department (ED). His initial blood gas showed a severe respiratory acidosis and hypoxemia: pH 6.62, pCO2 267, pO2 87, HCO3 28. A right Pneumothorax was identified and addressed with needle thoracentesis and placement of a 14 French chest tube. The team represented by the pediatric intensivist, ED physicians and respiratory care practitioners (RCP) began titrating 0.5 --1.0% Isoflurane via the Siemens Servo 900C anesthesia ventilator (Siemens Medical Systems, Danvers, MA) with anesthetic gas monitor at 0445. He demonstrated that he could tolerate weaning from Isoflurane by hand ventilating him for 30 minutes with oxygen and continuous albuterol aerosols. He was transported by to our facility's PICU and was placed on identical equipment used in the CCHC-ER. His initial ventilator settings included a tidal volume of 700 mL (10 mL/kg), PEEP=5, Rate/SIMV of 10/minute, FiO2 of 100% and Pressure support of 10cm H20. Isoflurane anesthetic gas at 0.5 % was initiated and titrated clinically based upon lung compliance, wheezing/aeration, and blood pressure. Some pertinent data on his course is summarized as follows: