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• W4387248930 abstract "SESSION TITLE: Bugs and Drugs in the ICU SESSION TYPE: Case Reports PRESENTED ON: 10/10/2023 08:30 am - 09:30 am INTRODUCTION: Intractable cough is often the bane of a provider's existence in terms of efficacious treatment options. Rarely is the case severe enough, however, that it becomes a life-threatening condition resulting in respiratory failure. CASE PRESENTATION: A 45 year old male presented to his primary care with a 3 day history of cough and nasal congestion. One year ago he had severe ARDS secondary to COVID-19 requiring intubation followed by two separate episodes of oropharyngeal swelling and bilateral vocal cord paralysis attributed to COVID and then GERD/reflux laryngitis requiring tracheostomy with subsequent decannulation shortly after. On this visit, he was diagnosed with a viral URI and prescribed oral steroids. Unfortunately his symptoms significantly worsened progressing to severe respiratory distress and intractable cough several days later. Upon emergency medical services arrival he was endotracheally intubated with an edematous vocal cord noted on direct laryngoscopy. Extensive workup for infectious and anatomical causes for his respiratory distress revealed viral PCR panel positive for human metapneumovirus and acute hypercapnic respiratory failure.He was admitted to the ICU on intravenous steroids. Laryngoscopy and tracheal inspection was performed with direct visual removal of the endotracheal tube. Vocal cords were normal appearing and there was no notable subglottic stenosis. The patient was extubated later that same day. Unfortunately immediately after extubation there was an intractable cough with severe desaturation and hypoxemia requiring reintubation.The patient was started on antitussives and continued on intravenous corticosteroids. The patient extubated himself several days later in the middle of the night. He did well initially but again had an intractable cough progressing to desaturation requiring reintubation several hours later with no laryngeal, vocal cord or subglottic edema noted. Two days later the patient was extubated with again an intractable cough that did not improve with the use of racemic epinephrine, albuterol, nebulized lidocaine, diazepam pushes, promethazine, lorazepam, midazolam, hydromorphone drip, sublingual morphine or non-invasive positive pressure ventilation. CT scan of the chest with contrast was unrevealing except for some signs of mild tracheomalacia (Image). Episodes of desaturation eventually started to occur again. Multidisciplinary discussion was undertaken and a trial of intravenous phenobarbital was used. Immediate improvement was noted in the patient's dyspnea and at the two hour mark the cough had resolved. DISCUSSION: Most of the evidence for treatment is anchored in chronic cough. Even then treatment options are limited, mechanistically poorly understood, and efficacy is variable across various antitussives [1]. Gabapentin has been studied and proven efficacious [2] but unfortunately our patient's cough was persistent to the point that he could not tolerate even sips of water. Barbiturates work differently than benzodiazepines by increasing the time chloride channels in the GABA-A receptor are open thereby reducing the number of receptors available for stimulation [3]. The dose of barbiturates inhibited his presumed vagal neuropathy from the human metapneumovirus infection of his upper airway. CONCLUSIONS: This case suggests that phenobarbital be considered as an adjunctive antitussive in severe and intractable cough. Further studies are required to support clinical efficacy. REFERENCE #1: Dicpinigaitis PV, Morice AH, Birring SS, McGarvey L, Smith JA, Canning BJ, Page CP. Antitussive drugs–past, present, and future. Pharmacol Rev 2014;66(2):468–512 REFERENCE #2: Ryan NM, Birring SS, Gibson PG. Gabapentin for refractory chronic cough: a randomised, double-blind, placebo-controlled trial. Lancet 2012;380(9853):1583–1589. REFERENCE #3: Lewis CB, Adams N. Phenobarbital. [Updated 2022 Jan 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532277/ DISCLOSURES: No relevant relationships by Muhammad Arian No relevant relationships by Jonathan Stoever" @default.
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• W4387248930 date "2023-10-01" @default.
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• W4387248930 title "PHENOBARBITAL: THE ULTIMATE ANTITUSSIVE" @default.
• W4387248930 doi "https://doi.org/10.1016/j.chest.2023.07.1368" @default.
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