A52-26 Severe Ammonia Inhalation Burn With Airway Injury and Refractory ARDS Managed With VV-ECMO: Case Report From a Quaternary Care Hospital in Colombia

Rationale Ammonia is a caustic chemical widely used in fuel processing, cleaning products, and agriculture. Owing to its highly alkaline nature, it causes liquefactive necrosis, protein denaturation, and fat saponification, producing severe tissue destruction. Moisture enhances its corrosive potential, particularly in mucosal surfaces. Airway involvement occurs in approximately 14% of ammonia burn cases and carries a mortality rate of up to 40%, largely due to acute respiratory distress syndrome (ARDS) development. Case Description A 37-year-old male sustained a workplace exposure to anhydrous ammonia, resulting in 20% total body surface area burns affecting the head, anterior right hemithorax, upper limbs, genitalia, and airway. He was referred from a primary care facility under invasive mechanical ventilation due to severe upper airway edema. Early tracheostomy and surgical management of skin injuries were performed.On day five, chest radiography revealed bilateral alveolar opacities and peribronchovascular thickening. Arterial blood gases demonstrated worsening hypoxemia (PaO2/FiO2 = 91) and hypercapnia (PaCO2 = 71 mmHg). Ventilatory mechanics showed elevated peak airway pressures (39 cmH2O), resistance > 24 cmH2O/L/s, and markedly reduced compliance. Fiberoptic bronchoscopy identified progressive edema and erythema involving segmental and subsegmental bronchi. Despite lung-protective ventilation, neuromuscular blockade, and prone positioning, oxygenation failed to improve.Veno-venous extracorporeal membrane oxygenation (VV-ECMO) was initiated with a RESP score of 1 (class III, predicted survival 57%) and a BAUX score estimating 85% survival probability. ECMO support was maintained for 10 days. Complications included a burn wound infection and Acinetobacter baumannii bacteremia, successfully treated with broad-spectrum antibiotics. Gas exchange and lung mechanics gradually improved, allowing successful decannulation and discharge after 35 days without further complications. Discussion This case highlights a rare but life-threatening presentation of combined thermal and chemical airway injury secondary to anhydrous ammonia exposure, progressing to refractory ARDS. The underlying pathophysiology involves diffuse airway and alveolar injury leading to impaired gas exchange and poor response to conventional ventilatory strategies. In this patient, timely VV-ECMO initiation provided effective oxygenation and CO2 removal, enabling lung rest and recovery while minimizing ventilator-induced injury.Reports describing ECMO use in ammonia-induced respiratory failure are scarce; however, existing evidence suggests that early initiation—within a multidisciplinary critical care framework—may be lifesaving. This case reinforces the importance of recognizing ECMO as a viable rescue strategy in caustic inhalation injuries when hypoxemia remains refractory to optimal mechanical ventilation. Conclusion VV-ECMO can serve as an effective rescue therapy for severe ammonia inhalation injury complicated by refractory hypoxemic respiratory failure. This abstract is funded by: None