Extracorporeal membrane oxygenation (ECMO) and beyond in near fatal asthma: A comprehensive review

Rapidly progressive mucus plugs in allergic bronchopulmonary mycosis

INTRODUCTION

Allergic bronchopulmonary mycosis (ABPM) is a chronic airway disease characterized by the presence of fungi that trigger allergic reactions and airway obstruction. Here, we present a unique case of ABPM in which a patient experienced sudden respiratory failure due to mucus plug-induced airway obstruction. The patient's life was saved by venovenous extracorporeal membrane oxygenation (VV-ECMO) and bronchoscopic removal of the plug. This case emphasizes the clinical significance of mucus plug-induced airway obstruction in the differential diagnosis of respiratory failure in patients with ABPM.

CASE STUDY

A 52-year-old female clerical worker with no smoking history, presented with dyspnea. CT scan revealed mucus plugs in both lungs. Despite treatment, the dyspnea progressed rapidly to respiratory failure, leading to VV-ECMO placement.

RESULTS

CT revealed bronchial wall thickening, obstruction, and extensive atelectasis. Bronchoscopy revealed extensive mucus plugs that were successfully removed within two days. The patient's respiratory status significantly improved. Follow-up CT revealed no recurrence. Fungal cultures identified Schizophyllum commune, confirming ABPM. Histological examination of the mucus plugs revealed aggregated eosinophils, eosinophil granules, and Charcot-Leyden crystals. Galectin-10 and major basic protein (MBP) staining supported these findings. Eosinophil extracellular traps (EETs) and eosinophil cell death (ETosis), which contribute to mucus plug formation, were identified by citrullinated histone H3 staining.

CONCLUSION

Differentiating between asthma exacerbation and mucus plug-induced airway obstruction in patients with ABPM and those with acute respiratory failure is challenging. Prompt evaluation of mucous plugs and atelectasis using CT and timely decision to introduce ECMO and bronchoscopic mucous plug removal are required.

Near fatal asthma in a case of allergic bronchopulmonary aspergillosis (ABPA) treated with ECMO

BACKGROUND

Fatal asthma is a rapidly progressing and highly fatal form of asthma. Mechanical ventilation, although necessary for respiratory support, can exacerbate the condition and lead to ventilator-associated lung injury. ECMO therapy is crucial in allowing the lungs to rest and recover, as it provides extracorporeal membrane oxygenation.

CASE PRESENTATION

A 40-year-old man presented with dyspnea following a mountain climb, which rapidly worsened, leading to respiratory failure and loss of consciousness. Despite drug therapy and mechanical ventilation, arterial blood gas analysis showed persistent hypercapnia. After 3 days of ECMO support, the patient was successfully extubated and underwent treatment for Aspergillus infection. Chest CT returned to normal after 3 months of anti-aspergillus therapy.

CONCLUSION

When drug therapy and mechanical ventilation fail to improve respiratory failure in fatal asthma, prompt initiation of ECMO support is essential to create opportunities for subsequent etiological treatment.