A 25 year old female, with a long history of asthma, had repeated attacks during the 2 days prior to admission, and was treated with steroids, valium and bronchodilators. She lapsed in to a coma on the day before admission. On examination, she had gasping respiration, rate 50/min, with very poor air entry on auscultation. Blood gases: pH 7.07; base excess 8.2
meq/l; standard bicarbonate 18.2 meq/l; Pa CO2 88mm Hg; Pa O2 49mm Hg; oxygen 67%. She was given hydrocortisone and aminophylline intravenously, intubated, and ventilated by hand with 100% oxygen. Her level of consciousness improved, but spontaneous respiratory effort was poor. To facilitate a changeover from orotracheal to nasotracheal tube, morphine was given. Bronchospasm increased, cardiac arrest occurred, and she died.
The lung is moderately collapsed and congested, due to absorption of alveolar air by unimpeded alveolar circulation consequent on bronchiolar obstruction. The large and
medium-sized bronchioles are thick-walled and their lumina are occluded by greyish-white, opalescent, jelly-like mucus plugs. It is these plugs, rather than bronchospasm, that have caused the pulmonary collapse, unconsciousness, anoxaemia and acidosis, as indicated by the blood gas results. The pulmonary vessels in the vicinity of the bronchi contain postmortem clot.
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