Assuming that a severe asthma attack had occurred the physician administered 0 ·09 mg reproterol (a β-2 agonist), 200 mg theophylline and 250 mg methylprednisolone through a properly placed intravenous line on her left arm. Heart rate increased to 170 bpm, yet without any relief of the respiratory distress. General anaesthesia was induced with 15 mg midazolam intravenous and 250 mg ketamine intravenous to facilitate endotracheal intubation. Laryngoscopy revealed no apparent obstruction, vocal cords were easily visualised but placement of the 7.5-mm cuffed endotracheal tube was hindered by distinct resistance that was finally overcome by repeated attempts of careful pressures. Even then, ventilation remained difficult with low tidal volumes of about 100 ml/breath. Expiratory measurement of end-tidal CO2 confirmed correct placement of the endotracheal tube and showed a considerably elevated partial pressure of >120 mm Hg. In order rule out/differentiate decreased respiratory compliance we administered a 1 mg/kg succinylcholine. This did not improve ventilation, although oxygen saturation improved gradually until reaching 100%.
Once stabilised on the scene, the patient was transferred to the Hospital's shock room. Surprisingly, chest x-ray was uneventful with no signs for any apparent airway obstruction. After half an hour, the parents of the patient arrived and reported a pre-existing Wegener's granulomatosis but no bronchial asthma. A fiberoptic bronchoscopy was performed and showed a bulk of granulomatous tissue () now located just above the tracheal bifurcation. The tissue was extracted and the ventilatory situation improved immediately.
Granulation tissue extracted from the distal trachea by flexible bronchoscopy.