Status asthmaticus treated by high-frequency oscillatory ventilation.

We present a 2.5-year-old girl in severe asthma crisis who clinically deteriorated on conventional mechanical ventilation, but was successfully ventilated with high-frequency oscillatory ventilation (HFOV). Although HFOV is accepted as a technique for managing pediatric respiratory failure, its use in obstructive airway disease is generally thought to be contraindicated because of the risk of dynamic air-trapping. However, we suggest that obstructive airway disease can safely be managed with HFOV, provided certain conditions are met. These include the application of sufficiently high mean airway pressures to open and stent the airways ("an open airway strategy"), lower frequencies to overcome the greater attenuation of the oscillatory waves in the narrowed airways, permissive hypercapnia to enable reducing pressure swings as much as possible, longer expiratory times, and muscle paralysis to avoid spontaneous breathing.