Use of Venovenous Extracorporeal Membrane Oxygenation in Status Asthmaticus: Case Reports

Bronchial asthma remains one of the most common chronic respiratory diseases characterized by episodes of severe airway obstruction. In cases of refractory status asthmaticus complicated by critical hypercapnia and decompensated respiratory acidosis, conventional methods of respiratory support, including mechanical ventilation, are often insufficient. The use of venovenous extracorporeal membrane oxygenation (VV-ECMO) is considered a promising method for stabilizing gas exchange and minimizing ventilator-induced damage.

Objective: to share clinical experience in successful use of VV-ECMO in patients with refractory status asthmaticus complicated by severe hypercapnia and decompensated respiratory acidosis, resistant to correction by conventional respiratory support and lung-protective ventilation.

Materials and methods. VV-ECMO was used as an extracorporeal alternative for lung gas exchange function in two female-patients with refractory status asthmaticus complicated by severe hypercapnia and decompensated respiratory acidosis.

Results. VV-ECMO reduced the risk of developing ventilator-induced lung injury (VILI) allowing maintenance of lung-protective mechanical ventilation, and therefore, enabling accelerated respiratory rehabilitation. In both presented cases, early initiation of VV-ECMO improved gas exchange parameters and mitigated ventilator-associated complications, thereby confirming the relevance of its’ use in patients with severe exacerbations of bronchial asthma complicated by uncontrolled hypercapnia.

Conclusion. Presented experience highlights the importance and feasibility of further VV-ECMO exploration as an intensified approach for management of severe BA exacerbations accompanied by critical hypercapnia and respiratory failure. This might require larger-scale randomized trials to identify optimal indications and protocols for VV-ECMO use.

1. Porsbjerg C., Melén E., Lehtimäki L., Shaw D. Asthma. Lancet. 2023; 401 (10379): 858–873. DOI: 10.1016/S0140-6736(22)02125-0. PMID: 36682372.

2. Hon K. L. E., Leung A. K. C. Medications and recent patents for status asthmaticus in children. Recent Pat Inflamm Allergy Drug Discov. 2017; 11 (1): 12–21. DOI: 10.2174/1872213X11666170130143524. PMID: 28137226.

3. Shigemura M., Homma T., Sznajder J. I. Hypercapnia: an aggravating factor in asthma. J Clin Med. 2020; 9 (10): 3207. DOI: 10.3390/jcm9103207. PMID: 33027886.

4. Kelly V. J., Hibbert K. A., Kohli P., Kone M., Greenblatt E. E., Venegas J. G., Winkler T., et al. Hypoxic pulmonary vasoconstriction does not explain all regional perfusion redistribution in asthma. Am J Respir Crit Care Med. 2017; 196 (7): 834–844. DOI: 10.1164/rccm.201612-2438OC. PMID: 28644040.

5. Bronchial asthma: clinical guidelines. Approved by the Scientific and practical council of the Ministry of Health of the Russian Federation. Moscow; 2024. ID 359_3. (in Rus.). URL: https://cr.minzdrav.gov.ru/view-cr/359_3.

6. Lammers S., Scott D., Hunter K., Tan W., Shandas R., Stenmark K. R. Mechanics and function of the pulmonary vasculature: implications for pulmonary vascular disease and right ventricular function. Compr Physiol. 2012; 2 (1): 295–319. DOI: 10.1002/cphy.c100070. PMID: 23487595.

7. Gayen S., Dachert S., Lashari B. H., Gordon M., Desai P., Criner G. J., Cardet J. C., et al. Critical care management of severe asthma exacerbations. J Clin Med. 2024; 13 (3): 859. DOI: 10.3390/jcm13030859. PMID: 38337552.

8. Zaidan M. F., Ameredes B. T., Calhoun W. J. Management of acute asthma in adults in 2020. JAMA. 2020; 323 (6): 563–564. DOI: 10.1001/jama.2019.19987. PMID: 32044931.

9. McFadden E. R. Jr. Acute severe asthma. Am J Respir Crit Care Med. 2003; 168 (7): 740–759. DOI: 10.1164/rccm.200208-902SO. PMID: 14522812.

10. Ekechukwu N., Batra S., Orsi D., Rahmanian M., Bangar M., Mohamed A. Outcomes of extracorporeal life support (ECLS) in acute severe asthma: a narrative review. Lung. 2024; 202 (2): 91–96. DOI: 10.1007/s00408-023-00667-x. PMID: 38512466.

11. Leatherman J. Mechanical ventilation for severe asthma. Chest. 2015; 147 (6): 1671–1680. DOI: 10.1378/chest.14-1733. PMID: 26033128.

12. Yaroshetsky A. I. Respiratory support as if by notes. From the point of view of the patient’s physiology and evidence-based medicine. M.: Eksmo; 2023: 640. (in Rus.). ISBN 978-5-04-191153-9.

13. Brogan T. V., Thiagarajan R. R., Rycus P. T., Bartlett R. H., Bratton S. L. Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med. 2009; 35 (12): 2105–2114. DOI: 10.1007/s00134-009-1661-7. PMID: 19768656.

14. Zakrajsek J. K., Min S. J., Ho P. M., Kiser T. H., Kannappan A., Sottile P. D., Allen R. R. et al. Extracorporeal membrane oxygenation for refractory asthma exacerbations with respiratory failure. Chest. 2023; 163 (1): 38–51. DOI: 10.1016/j.chest.2022.09.029. PMID: 36191634.

15. Lozano-Espinosa M., Antolín-Amérigo D., Riera J., Gordo Vidal F., Quirce S., Álvarez Rodríguez J. Extracorporeal membrane oxygenation (ECMO) and beyond in near fatal asthma: a comprehensive review. Respir Med. 2023; 215: 107246. DOI: 10.1016/j.rmed.2023.107246. PMID: 37245648.

16. Xu J., Tian L., Han X. Successful treatment of near-fatal asthma with ECMO: a case report and literature review. Int J Artif Organs. 2023; 46 (8–9): 532–536. DOI: 10.1177/03913988231182163. PMID: 37345330.

17. Medar S. S., Peek G. J., Rastogi D. Extracorporeal and advanced therapies for progressive refractory near-fatal acute severe asthma in children. Pediatr Pulmonol. 2020; 55 (6): 1311–1319. DOI: 10.1002/ppul.24751. PMID: 32227683.

18. McLellan T., Patvardhan C., Rassl D., Jenkins H. S., Knolle M., Thillai M. Asthma, ECMO and eosinophils. Thorax. 2021; 76 (7): 737–739. DOI: 10.1136/thoraxjnl-2020-216052. PMID: 33495316.