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Case based discussion
Asthma, ECMO and eosinophils
  1. Tom McLellan1,
  2. Chinmay Patvardhan2,
  3. Doris Rassl3,
  4. Huw Steven Jenkins4,
  5. Martin Knolle5,6,
  6. Muhunthan Thillai1,6
  1. 1Interstitial Lung Disease Service, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
  2. 2Critical Care Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
  3. 3Department of Histopathology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
  4. 4Respiratory Medicine, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK
  5. 5Asthma & Allergy Service, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
  6. 6Department of Medicine, Cambridge University, Cambridge, Cambridgeshire, UK
  1. Correspondence to Dr Tom McLellan, Interstitial Lung Disease Service, Royal Papworth Hospital NHS Foundation Trust, Cambridge, CB2 0AY, UK; tom.mclellan{at}nhs.net

http://dx.doi.org/10.1136/thoraxjnl-2020-216052

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    Tom McLellan (specialty respiratory registrar)

    A man in his 30s, with a history of mild childhood asthma only, went to his local hospital with difficulty in breathing. His presentation was preceded by 6 days of worsening breathlessness, wheeze and cough. He had been using his mother’s salbutamol inhaler and received oral amoxicillin in the community. He was hypertensive, tachycardic and had a respiratory rate of 32 breaths/min. He could not complete sentences, peak flow measurement or lie flat. Chest auscultation revealed diffuse polyphonic wheeze. Arterial blood gas (ABG) while receiving fraction of inspired oxygen (FiO2) 40% revealed pH 7.32, PaO2 9.7 kPa, PaCO2 6.7 kPa. He had a blood eosinophil count of 0.5×109/L, serum C-reactive protein of 30 mg/L with normal renal and liver profiles. His chest radiograph (figure 1A) revealed clear lung fields with no pneumothorax or consolidation. He was treated with nebulised bronchodilators, intravenous broad-spectrum antibiotics, magnesium, hydrocortisone and aminophylline before transfer to the high dependency unit.

    Figure 1

    (A) Presentation chest radiograph. (B) CT thorax, day 1 extracorporeal membrane oxygenation (ECMO) treatment. (C) Summary of antibiotic and steroid therapy, change in blood eosinophil and bronchoalveolar lavage (BAL) % and ECMO sweep requirements (necessary to clear CO2). Shaded area is time spent on ECMO. Key: MP, methylprednisolone; Vc, vancomycin (D). Eosinophil-rich BAL.

    Over 48 hours, there was an improvement and treatments were gradually weaned but on day 3 there was a respiratory deterioration associated with a PaCO2 of 7.6 kPa requiring intubation. Treatment was augmented with a ketamine infusion and inhaled sevoflurane. Despite optimum ventilation strategies, 4 hours after intubation there was severe gas trapping requiring manual decompression, low tidal volumes and a rising arterial PaCO2. A referral to the local extracorporeal membrane oxygenation (ECMO) centre was made.

    Chinmay Patvardhan (consultant intensivist)

    On our arrival, the patient was in ventilatory failure with severe gas trapping. Pre-ECMO …

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    Footnotes

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    • Contributors All authors contributed to the conception, design, editing and production of the case report. All authors contributed to the drafting and revision of the manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.