Case history

A 2-year-old girl, with eczema and recurrent wheeze, was transferred from a district general hospital to the regional paediatric intensive care unit (PICU), following intubation. For 2 hours prior to intubation, she received continuous salbutamol and ipratropium nebulisers, hydrocortisone (4 mg/kg), magnesium sulfate, aminophylline (loading dose and infusion) and a loading dose of intravenous salbutamol. Despite this, she tired and developed type 2 respiratory failure, necessitating intubation with a 4.0 endotracheal tube (ETT), which was secured nasally at 17 cm.

On arrival at the PICU, her wheeze had completely resolved. Chest radiograph showed left lower lobe consolidation, and bronchoalveolar lavage revealed purulent secretions. She was treated with intravenous antibiotics. Aminophylline infusion was stopped and nebuliser therapy spaced overnight to four hourly.

The following morning, she suffered a sudden deterioration. Oxygen requirement rose from 21% to 60% and inspiratory pressure maintaining a tidal volume of 7 mL/kg (normal target 6–8 mL/kg) increased from 18 to 28 cm H₂O. …