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Therapeutic unresponsiveness: case report A 2-year-old girl exhibited unresponsiveness to aminophylline, salbutamol, magnesium sulfate and terbutaline, indicated for status asthmaticus [dosages and routes not stated]. The girl, who had moderate persistent asthma, developed a 5-day history of rhinorrhoea and cough that progressed to wheezing and difficulty breathing (status asthmaticus). She presented to the emergency department and received treatment with ipratropium bromide, methylprednisolone and salbutamol [albuterol] nebulisation. However, no significant improvement was noted. She was admitted to the paediatric ICU (PICU). Physical examination revealed that she was somnolent but arousable, and she had marked intercostal, suprasternal and subcostal retractions with diminished air entry bilaterally. Chest X-ray revealed right-sided perihilar opacities, but no obvious consolidation. She was initially started on high-flow nasal cannula, continuous infusions of salbutamol [albuterol], terbutaline, magnesium sulfate and aminophylline drip. Within a few hours, doses of the ongoing medications were increased. Despite this treatment, she had respiratory distress and poor air entry. Blood gas analysis revealed marked hypercarbia at 5h following PICU admission. She required endotracheal intubation and mechanical ventilation due to respiratory fatigue, hypercarbia and worsening respiratory failure. She was sedated with fentanyl, midazolam and ketamine drips, and was paralysed with vecuronium bromide [vecuronium] drip to prevent ventilator asynchrony and high peak pressure. High-frequency oscillatory ventilation (HFOV) was initiated, and within 25 min an improvement in alveolar ventilation was observed. The continuous infusions of terbutaline, aminophylline and magnesium sulfate remained unchanged. HFOV was discontinued after 5 hours, and conventional mechanical ventilation was resumed. She was extubated after 5 days with no further complications. Sharma K, et al. High-frequency oscillatory ventilation as a rescue for severe asthma crisis in a child. SAGE Open Medical Case Reports 8: 10 Sep 2020. Available from: 803505861 URL: http://doi.org/10.1177/2050313X20957454

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Reactions 10 Oct 2020 No. 1825