Critical asthma syndrome in trauma patients - A case report and literature review

Critical asthma syndrome (CAS) is an umbrella term for many acute, life-threatening, and treatment resistant variants of asthma exacerbation, including refractory asthma, near fatal asthma, and status asthmaticus. The asthma mortality rate has steadily increased through the last decade and disproportionately affects women, African-Americans, patients of low socioeconomic status, and adults over the age of 55. Increased awareness of the diagnosis and therapies for CAS can help establish a therapeutic strategy for asthma beyond corticosteroids, bronchodilators, and other conventional treatments. A 37 year-old African American woman presented to our Level 1 Trauma Center after a high-speed motor vehicle crash and was intubated on arrival for airway protection. The patient developed diffuse wheezing and persistent tachycardia, with elevated peak airway pressures and air trapping on mechanical ventilation. Her symptoms were refractory to inhaled steroids, systemic steroids, intravenous magnesium, continuous albuterol administration and ventilator optimization. Heliox, an admixture of 80:20 percent helium to oxygen, was initiated to assist with laminar flow. Throughout the next 24 h, the patient's air trapping improved, subsequently decreasing intrathoracic pressure, improving venous return and resolving her tachycardia. The patient's multiple orthopedic injuries were treated and she was eventually weaned off of Heliox, steroids, and continuous albuterol. She was extubated and endorsed a history of poorly controlled asthma requiring hospitalizations and multiple intubations. Recognition of CAS can be challenging in the trauma patient with distracting injuries. This case illustrates the utility of a stepwise approach to a trauma patient suffering from CAS, and should encourage further research into novel therapies when conventional treatment fails. Given that the populations most affected by CAS are often also subject to a disproportionate burden of trauma, trauma surgeons should maintain both a vigilance for the syndrome as well as a working knowledge of the treatment modalities available.