UC Irvine

Background

Status asthmaticus respiratory failure is associated with thickened mucus secretions necessitating aggressive pulmonary clearance. The role of bronchoscopy in pediatric mechanically ventilated asthmatic patients has not been published.

Methods

A chart review was performed on all pediatric intensive care unit (PICU) asthmatics with respiratory failure over 13 years. Forty-four patients were identified. Patients were managed per standardized guidelines for status asthmaticus with mechanical ventilation. Ventilator management prioritized spontaneous breathing with pressure support. Extubation criteria included spontaneous tidal volumes of 5-7 cm(3) /kg on low-pressure support. Standard endotracheal tube pulmonary toilet were implemented. Twenty-nine patients underwent bronchoscopy as an adjunctive therapy. Indications for bronchoscopy included: Pathogen identification via bronchoalveolar ravage, atelectasis, mucus obstruction resulting in severe air trapping, suspected aspiration, and poor response to standard therapy. Clinical outcomes of this intervention were compared to the fifteen patient cohort who did not undergo bronchoscopy.

Results

Bronchoscopies revealed thick mucus plugs, secretions, and bronchial casts. The large airways were lavaged for clearance of obstructive secretions with normal saline. All patients tolerated the procedure without any complications. Demonstrable improvement in pulmonary compliance was noted. The median time of intubation for the bronchoscopy group was 10 hr compared to 20.5 hr for the control group (P < 0.0005). The mean intensive care unit length of stay was 3.06 days for the bronchoscopy group versus 3.4 days for the non-bronchoscopy group (P < 0.05).

Conclusion

Flexible bronchoscopy with bronchial lavage is a safe adjunctive therapy in pediatric asthmatics with respiratory failure resulting in reduced mechanical ventilation and intensive care length of stay. Restoring lung volume in certain asthmatics during respiratory failure may be deemed beneficial. Further validated studies are necessary to recommend bronchoscopy to the present, accepted treatment regimen in pediatric asthmatic respiratory failure.