‘American Journal of Therapeutics 7, 325-327 (2000) Sodium Bicarbonate Solution Nebulization in the Treatment of Acute Severe Asthma Tosaddak Ahmed,* Ayman Iskandrani, and Mirza Nazim Uddin This is a case report of a 15-year-old asthmatic girl who was admitted with a severe acute attack of bronchial nebulization, thma who eventually recovered, possibly with the help of sodium bicarbonate solution Keywords: severe asthma, sodium bicarbonate nebulization. A 15-year-old girl was admitted with a 3-day history of cough, sputum, fever, and worsening wheezing. breathlessness. She has had severe asthma since early childhood and regularly attends the chest outpatient clinic. She has also required hospital admission for acute attacks of asthma several times in the past. Her mother is also asthmatic. EXAMINATION Her pulse was 140 beats per minute, blood pressure was 130/80 mm Hg, respiration was 38 breaths per minute, and her temperature was 37°C, She was un- derweight. Widespread, high-pitched wheezing. sounds were audible, INVESTIGATIONS Her hemoglobin was 13.2 gm% and her white blood cell count was 17,600/emm and platelets were 229,000/emm. Blood glucose, urea, creatinine, s0- dium, potassium, aspartate transaminase, alanine transaminase, alkaline phosphatase, and bilirubin val- tues were normal. A chest radiograph showed hyper- Department of Chest Medicine, King Fahad Hospital, Madinah Al-Munawara, Kingdom of Saudi Arabia “Address for correspondence: P.O, Box 74, 41321, Madinah Al- Munawara, Kingdom of Saudi Arabia 1075-2765 © 2000 Lippincott Williams & Wilkins, Inc inflated lung fields. Arterial blood gas values are out- lined in Table 1, TREATMENT AND PROGRESS After admission, the severity of the asthma attack did not abate, despite high-dose intravenous steroids and bronchodilators. Approximately 24 hours after admis- sion, she became exhausted and breathing became shallow. She was intubated and started on mechanical ventilation. The airway pressure was found to be ex- tremely high at 70 cm H,O and remained at that level, even though the intravenous dose of hydrocortisone was increased to 500 mg every 4 hours, and the bron- chodilators were given at the maximum dose. After being on the ventilator for 12 hours, she was started on epinephrine 0.5 mg subcutaneously every 4 hours and was watched so that her heart rate did not rise above 140 beats per minute, and was given sodium bicarbon- ate 2.1% 10-mL solution nebulization every 6 hours. ‘The airway pressure remained very high and fixed at 70cm H,O. The artificial ventilation was continued at different rates and oxygen concentrations under in- travenous pancuronium bromide infusion to maintain Po; at a safe level. Hypercapnia (Pco, value rising to 129.6 mm Hg) and hypoxia (Po; -80 mm Hg) per- sisted. Fortunately no barotrauma complication oc- curred. Approximately 44 hours after the mechanical ven- tilation was started, copious mucoid secretion was seen coming out through the endotracheal tube. This was regularly sucked out. Thereafter, the airway re- sistance steadily decreased. Approximately 60 hours326 AHMED ET AL Table 1. Patient’s arterial blood gases and progress with treatment, Dateltime 1/20/98 21 121 121 22 9PM. 3:30 P.M, 8:30 P.M 10:30 P.M. 9AM, Oxygenation and 0,-6Umin in Q,-16 Lmin in Intubated and ACMV; "Fro: ‘CMV; Fiog: 100; ‘mechanical mask mask ‘mechanical 100%; BR: RR: 16; TV: ventilation ventilation 12/min; TV: 400 400; AWP: 70 started mL; AWP: 70 em H,0 Arterial blood 7311 7.196 7.255 739 gases (pH) Pos (mmHg) 110.2 1233 83.0 73.0 Poo, (mmHg) 45.5 58 632 55.8 SPo, (%) 97.5 97.4 99.8 94.0 HCO, (mmol) 22.5 245 27.2 33.4 Medications Hydrocortisone Same as before Same as before Hydrocortisone Added 300 mai hiv, dose increased epinephrine 0.5 Salbutamo! t0.500mgi4h —_ mg/d h sic. nebulizer iv.+sameas Sodium 5 mgi6 h before bicarbonate | Ipratropium 2.1% 10 mL | nebulizer nebulization/6 h 250 mgi6 h Erythromycin 500, | Aminophylline mg iv. 480 mg inv. infusion/6 h + infusion over same as before 26h Cofotaxime Tgivi8 h later, she was taken off the ventilator and after another day she was extubated (Table 1). She made a full recovery and was not breathless on. usual ambulation and activities. Her chest was clear on auscultation. Arterial blood gas values in room air returned to normal level. She was discharged 8 days after extubation on inhaler bronchodilators (salbuta- mol, ipratropium), a steroid (beclomethasone), reduc ing dose of prednisolone tablet, and oral antibiotics (erythromycin and co-amoxiclav), DISCUSSION When the airway pressure was seen to remain very high (70m H,O) and fixed for more than 44 hours, it was presumed that the airways had been clogged with inspissated secretion. The expulsion of profuse mu- coidl sputum through the endotracheal tube followed by relief of the airway obstruction was rather unex- pected. Before this happened, she already had re- ceived a total of six doses of sodium bicarbonate 2.1% 10-mL solution nebulization over the previous 33 American Journal of Therapeutis (2000) 7(5) (continued) hours, Itis possible that the nebulized alkali facilitated liquifaction of the hard secretion in the airways. It is, known that the bronchial secretion during acute attack of bronchial asthma is acidie, and the acidity imparts, a stickiness to the secretion.’ There is high level of rneuraminic acid in sputum in acute asthmatics, which. positively correlates with sputum viscosity. There- fore, neutralization of this acidity would make the sputum loose and thin, Moreover, the acidic environ- ‘ment of the airways may aggravate bronchoconstric- tion through the vagal reflex, and alkali nebulization would promote bronchodilatation by reducing the acidity in the airways.? ‘Alkali nebulization was administered to this patient in desperation, and the surprising favorable outcome might have been brought about by the nebulized al- kali. ACKNOWLEDGMENT We thank the nursing staff at the Medical Intensive Care Unit for their care of this patient. We also thank Belinda Zurbano for typing the tableSODIUM BICARBONATE NEBULIZATION FOR ASTHMA. Table 1. Continued 327 Dateltime 123 1/23 1128 127 1/28 130 2PM. 6:45 P.M 6:20 AM, 10:30 A.M, 6:30 P.M. 10 AM. ‘ACM; Fio;: 70; ACMV; Fi: 65; 04-60% in 0,-40% in 2-6 Umin in Room air RR: 0; TV: RR: 25; TV: T-Piece Venturi mask; nasal prongs 350; AWP: 70 350; AWP: 55 connection extubated with: endotracheal tube; ventilator disconnected 7.144 7.475 7.497 7.495 781 7811 83.6 616 70.1 70.2 597 893 103.0 529 a8 34.1 33.4 328 873. 929 95.3 95.4 93.0 97.6 353 388 32.3 26.2 268 26.2 Same as before Same as before Sodium Sodium, Hydrocortisone Hydrocortisone bicarbonate bicarbonate reduced to 100 stopped nebulization concentration mg/6hiv.+ — Prednisolone reduced to lowered to 1% © sameas before _ started 30 mg/d m6 h 10 mU6 h + i.v. erythromycin Epinephrine same as before ‘changed to stopped tablet 500 mg/6 h (hydrocortisone Sodium reduced to 300 bicarbonate mgi6 h on nebulization 1124) + same stopped on 1/29 as before: + same as before ‘Abbreviations: ACMV, assisted control mode ventilation; Fi, fraction of inspired oxygen; RR, respiratory rate; TV, tidal volume; AWP, airway pressure, REFERENCES 1. Ryley HC, Brogan TD: Variation in the composition of sputum from patients with chronic bronchitis. } Clin Pathol 1968;49:625-693. 2, Keal EE: Biochemistry and rheology of sputum in asthma, Postgrad Med J 1971;47:171 3. Ahmed 7, Ali JM, AlSharif AF: Effect of alkali nebull- sation on bronehoconstriction in acute bronchial asthma, Respir Med 1993;87.235-236, American Journal of Therapeutics