Abstract Introduction Chronic or recurrent bronchospasm in children is most often attributed to severe asthma or to chronic lung disease of prematurity, particularly bronchopulmonary dysplasia (BPD). Many children with severe BPD require tracheostomy and long-term ventilation, leaving them with fragile airways that are highly susceptible to acute episodes of bronchospasm. In severe asthma driven by type-2 inflammation, biologic therapies have been shown to reduce exacerbations and improve lung function. However, a subset of medically complex patients remains refractory to both standard therapies and biologics, underscoring a gap in current management approaches Case A 6-year-old boy born at 24 weeks’ gestation with a complex medical history including bronchopulmonary dysplasia (BPD), tracheomalacia, severe asthma, chronic respiratory failure, tracheostomy with ventilator dependence, gastroesophageal reflux disease, and dysphagia requiring gastrostomy tube feeds. He experienced recurrent hospitalizations for life-threatening episodes of severe bronchospasm. Despite maximal bronchodilators, high-dose corticosteroids and adjunctive treatment with dupilumab (an IL-4 receptor-α antagonist) for a presumed type-2 asthma component, his wheezing and respiratory exacerbations continued uncontrolled. A comprehensive evaluation, including immunologic work up including IgE 21 IU/mL, normal vaccine titres, peripheral eosinophils 8. 5%, absolute eosinophil count 0. 72x10³/uL, bronchoalveolar eosinophilia of 3% and negative allergy testing. Concern for secondhand smoke exposure given maternal smoking history, urine nicotine testing was negative. Bronchoscopy revealed diffuse airway malacia without a fixed obstruction, and bronchoalveolar lavage cultures grew Pseudomonas aeruginosa for which he was treated with ciprofloxacin and nebulized tobramycin. He required multiple pediatric ICU admissions for respiratory failure. During the most severe episodes, deep sedation and inhaled sevoflurane anesthesia were used to achieve bronchodilation. Additional therapies such as heliox and continuous intravenous aminophylline infusions were trialed with only partial response. Thoracic imaging demonstrated chronic lung changes consistent with BPD but no acute process to explain the refractory bronchospasm. This abstract is funded by: na
Osei-Kuffuor et al. (Fri,) studied this question.