Case report

A 16 year old man, with a history of asthma that had needed hospital admission on several occasions, was referred to the intensive care unit with a diagnosis of acute severe asthma. Seven weeks earlier he had sustained a head injury in a road traffic accident and had been mechanically ventilated through an oral tracheal tube for 84 hours at another hospital. Subsequently he had been transferred to a neurological rehabilitation unit. Two days after admission he complained of exertional dyspnoea and wheeze. Although treatment with bronchodilators was started, his symptoms worsened progressively over the next two weeks, and he became acutely dyspnoeic at rest. He was transferred to an acute medical ward but continued to deteriorate despite receiving nebulised bronchodilators, intravenous hydrocortisone, aminophylline, and antibiotics. He became exhausted within 24 hours and was thus referred to our intensive care unit for further management.

On admission he was in extremis and had tachypnoea (respiratory rate 30/min), a virtually silent chest, and hypercarbia (partial pressure of carbon dioxide 9.3 kPa) on arterial blood gas analysis. We decided to intubate and ventilate him. After intravenous induction of anaesthesia, laryngoscopy was performed, with a good view of a normal glottis, but it …