Acute respiratory failure in a young asthmatic patient.

A 20-year-old woman was admitted to the intensive care unit following resuscitation from respiratory arrest associated with acute severe asthma. Examination of the chest revealed marked wheezing with equal intensity of breath sounds bilaterally. She was mechanically ventilated and given intravenous aminophylline, salbutamol and hydrocortisone, as well as nebulized salbutamol. Her inspiratory airway pressure was in excess of 65 cm H,O. The first blood gas analysis showed: PaO,, 148 mm Hg; PaCO,, 39 mmHg (F1o2 = 0.4). The chest radiograph (Fig 1) showed hyperinflation of the lungs. Three hours after admission, the patient became cyanotic and hypotensive. Diminished movement of the right side of the chest was noted and breath sounds over the right lung were absent. The Pa02 was 35 mmHg and the PaCO, was 42 mmHg (Flo, = 0.9). Another chest film was obtained (Fig 2) and subsequently an intercostal drain was inserted into the right pleural space. A small amount of air was noted to bubble through the underwater drain, the water level of which moved adequately with respiration. The patient remained cyanotic with absent breath sounds over the right lung. A diagnostic procedure was performed.