Muhammad Ashraf, Munawar Khan Mahsud.
Subcutaneous air: an unusual presentation of status asthmaticus with difficulties in ventilator management.
J Pak Inst Med Sci Jan ;6(1,2):380-2.

The article illustrates the difficulties encountered in ventilating the patients with severe airflow obstruction. Current methods and issues are discussed. This article deals with the principles of ventilator management in the intubated patient with severe bronchial asthma.

A 14 year old patient presented in the emergency room on 14-10-1995 with one week history of cough, shortness of breath and progressive wheezing. He complained of sore-throat in the emergency room and difficulty in swallowing. He was treated with large dose of intravenous steroids, intravenous aminophylline, and inhalational betaagonists. He did not respond to this treatment. Chest X-ray on admission revealed presence of subcutaneous air (surgical emphysema). In the next 2 to 3 hours he progressed into respiratory failure and was intubated and shifted to intensive care unit. He was placed on the ventilator and ABGs obtained in ICU on arrival revealed PH. 7.24 PC02 75 P0240 HC03 17. He was placed on the ventilator and intravenous pavalon was given. There was tremendous difficulty in bagging this patient prior to placement on the ventilator. Heart rate went upto 160-180, B.P. 140/90 on the ventilator T.V. of 600 cc R.R. 16/min. Flow rate at 50 L/unit, started to result in peak airway pressure reaching beyond 65 cm HO2. Patient started to show some intrinsic PEEP around 10 Cm H02 when listened with stethoscope. When the ventilator was disconnected the expiration was severely prolonged. Additional steroids were administered and the tidal volume was reduced to 500 cc and peak flow increased to 55 L/unit and the respiratory rate was reduced to 12 to allow more time for expiration and reduce the intrinsic PEEP. The heart rate was staying around 140-150 and B.P. showing drop in systolic to 100 and subsequently 90 and narrowing of the pulse pressure.

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