Clinical and Laboratory ObservationsLife-threatening status asthmaticus treated with inhaled nitric oxide☆
Section snippets
Case presentation
An 8-year-old patient with wellcontrolled asthma developed upper respiratory infection symptoms 24 hours before hospital admission. Increasing respiratory distress was treated with nebulized albuterol (2.5 mg) every 2 hours and oral prednisone (1 mg/kg) 10 hours before admission.
Four hours before admission to the pediatric intensive care unit, respiratory distress worsened: respiratory rate of 50 breaths/min, visible cyanosis, and profound suprasternal, intercostal, and subcostal retractions
Methods
Children with life-threatening asthma, defined as acute respiratory failure requiring mechanical ventilation, PaCO2 >90 mm Hg, or a hypoxemia score <150 (PaO2/fraction of inspired oxygen ratio) despite maximal medical management, were eligible to receive inhaled NO. Maximal medical therapy consisted of intravenous methylprednisolone (2 mg/kg, up to 100 mg/dose) administered at least 6 hours before NO therapy, at least 3 hours of continuous nebulized albuterol at 10 to 20 mg/h, intravenous
Results
In the 40 months after the index case, 37 children required mechanical ventilation for respiratory failure secondary to severe asthma. Four consecutive children with life-threatening asthma who met study inclusion criteria were treated with inhaled NO. Median age was 11.5 years (range, 4.1-16 years); there were 3 boys and 1 girl. Patient 2 was treated on a compassionate use basis while awaiting institutional review board approval of our amended protocol and was titrated only to 20 ppm. Patient
Discussion
Inhaled NO produced rapid improvement in ventilation in 4 of 5 children with life-threatening asthma who did not respond to maximal conventional therapy. The mechanism by which NO improves ventilation is unclear, but some data suggest that NO plays an important role in regulating bronchial smooth muscle tone.3, 6, 7, 8
Nitric oxide and vasoactive intestinal peptide appear to be the neurotransmitters released from the inhibitory non-adrenergic, non-cholinergic nerves, which innervate the
References (12)
- et al.
Dose-response to inhaled nitric oxide in pediatric patients with pulmonary hypertension and acute respiratory distress syndrome
J Pediatr
(1997) - et al.
Asthma
N Engl J Med
(1992) Asthma-United States, 1980-1987
MMWR Morb Mortal Wkly Rep
(1990)- et al.
Nitric oxide and bronchial reactivity
Clin Exp Allergy
(1994) - et al.
Virus-induced changes in airway responsiveness, morphology, and histamine levels in guinea pigs
Am Rev Respir Dis
(1993) Neural mechanisms in asthma
Br Med Bull
(1992)
Cited by (15)
Successful Treatment of Refractory Status Asthmaticus Accompanied by Right Ventricular Dysfunction Using a Protek Duo Tandem Heart Device
2019, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :Because of the evidence of RV dysfunction, the patient was taken to the operating room with a transport ventilator for placement of a RV assist device with ECMO capability (Protek Duo Tandem Heart, 31 French, TandemLife, Pittsburgh, PA) while maintaining sedation using intravenous infusions of propofol (55 μg/kg/min), fentanyl (1 μg/kg/h), and cisatracurium (1 μg/kg/min). Use of selective pulmonary vasodilators has been described previously in patients with status asthmaticus,8,9 but this option was not considered here. The patient remained hemodynamically stable despite his worsening respiratory status.
Inhaled nitric oxide for acute asthma
2006, Journal of PediatricsCurrent management of status asthmaticus in the pediatric ICU
2005, Critical Care Nursing Clinics of North AmericaNitric oxide: Indications in pediatrics
2005, Anales de Pediatria ContinuadaEmergency department management of pediatric asthma
2004, Clinical Pediatric Emergency MedicineComplementary treatments: Nitric oxide, prone positioning and surfactant
2003, Anales de Pediatria
- ☆
Reprint requests: Thomas A. Nakagawa, MD, Children’s Hospital of The King’s Daughters, Division of Pediatric Critical Care, 601 Children’s Ln, Norfolk, VA 23507.