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Updated: Dec 7, 2025
A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation
Published on: January 17, 2011
High-frequency oscillatory ventilation as a rescue for severe asthma crisis in a child
Kamal Sharma1, Ivan Von Hack-Prestinary2, Rosa Vidal1
1Division of Pediatric Critical Care, Department of Pediatrics, College of Medicine, University of South Alabama, Mobile, AL, USA.
Insights
High-frequency oscillatory ventilation may be a life-saving rescue treatment for children with severe asthma and respiratory failure. This approach can help manage persistent airflow obstruction and high carbon dioxide levels when other methods fail.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Medicine
- Emergency Medicine
Background:
- Mechanical ventilation in pediatric asthma can lead to dynamic air trapping, risking hemodynamic compromise and cardiac arrest.
- High-frequency oscillatory ventilation (HFOV) is often contraindicated in asthma due to hyperinflation risks compared to conventional mechanical ventilation (CMV).
Observation:
- A 2-year-old girl with severe status asthmaticus required intubation and CMV due to persistent respiratory distress and worsening hypercarbia (PCO2 > 134 mmHg).
- Despite maximal medical therapy and CMV, severe airflow obstruction and hypercarbia persisted, placing the patient at high risk for dynamic air trapping and cardiovascular collapse.
- The patient's condition necessitated a switch to HFOV.
Findings:
- Initiation of HFOV resulted in a significant decrease in arterial PCO2 from over 134 mmHg to 87 mmHg within 2 hours.
- HFOV was successfully used as a rescue therapy to overcome severe airflow obstruction and hypercarbia.
- Following HFOV treatment, the patient was transitioned back to CMV and successfully extubated after 5 days without complications.
Implications:
- This case suggests HFOV can be a valuable rescue modality in pediatric patients with severe status asthmaticus refractory to conventional treatments.
- HFOV may help mitigate risks associated with dynamic air trapping and hemodynamic compromise in severe pediatric asthma exacerbations.
- Consideration of HFOV as a rescue strategy should be evaluated in pediatric cases of severe asthma with persistent hypercarbia and airflow obstruction.
Abstract:
Mechanical ventilation in the asthmatic child may be complicated by dynamic air trapping leading to hemodynamic compromise and cardiac arrest. High-frequency oscillatory ventilation is relatively contraindicated because it may cause hyperinflation compared to conventional mechanical ventilation. A 2-year-old girl (weight, 11 kg) with a history of asthma was admitted because of status asthmaticus. Despite treatment with intravenous methylprednisolone, continuous albuterol, terbutaline, aminophylline, and magnesium sulfate, she had persistent respiratory distress. She required endotracheal intubation and mechanical ventilation because of worsening respiratory fatigue and hypercarbia ((PCO2), 96 mm Hg). Severe airflow obstruction persisted, and the hypercarbia worsened despite conventional mechanical ventilation (PCO2 > 134 mm Hg). It was judged that the patient was at risk for dynamic air trapping leading to hemodynamic compromise and cardiac arrest. High-frequency oscillatory ventilation was started to overcome airflow obstruction, and a decrease in arterial PCO2 to 87 mm Hg was observed within 2 h. High-frequency oscillatory ventilation was discontinued after 5 h, and conventional mechanical ventilation resumed. The patient was extubated after 5 days without further complications. In summary, this case shows that high-frequency oscillatory ventilation may be considered as a rescue treatment in children who have severe status asthmaticus with persistent airflow obstruction and hypercarbia unresponsive to pharmacological therapy and conventional mechanical ventilation.
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