C52-22 Pneumothorax, Pneumomediastinum, Pneumoperitoneum in Young Asthmatic on Mechanical Ventilation

Abstract Young individuals with known small airway disease, might encounter serious exacerbations that may necessitate noninvasive positive pressure therapy (NIPPV) or invasive ventilation. The combination of underlying lung disease and aggressive ventilatory support increases susceptibility to barotrauma, leading to life-threatening conditions such as pneumothorax and pneumomediastinum. Simultaneous pneumothorax and Pneumomediastinum is a rare complication of asthma with data suggesting less than 0.5% of patients with status asthmaticus might suffer from one or both. Close and frequent monitoring, lung-protective ventilation and neuromuscular blockade are crucial for improving outcomes. We present a case of a 27-year-old asthmatic male who developed simultaneous subcutaneous emphysema, pneumothorax, pneumomediastinum, and pneumoperitoneum following NIPPV and mechanical ventilation. Case Presentation A 27-year-old male with PFT-proven asthma and noncompliance with his maintenance regimen presented with acute dyspnea after two days of flu-like symptoms. Infectious workup was positive for rhinovirus. Given initial hypercapnia, tachypnea, and accessory muscle use, the patient was placed on BiPAP. A subsequent chest X-ray raised concerns for subcutaneous emphysema in the neck, which was confirmed by physical examination revealing crepitus over the trapezius. A CT scan of the chest confirmed subcutaneous emphysema with concurrent small left-sided pneumothorax and pneumomediastinum. BIPAP was initially continued however worsening status led to overnight intubation and mechanical ventilation. His ICU stay was prolonged by a worsening left-sided pneumothorax, the development of a new right-sided pneumothorax, and the extension of pneumomediastinum into the peritoneum. Bilateral chest tubes were placed, while pneumomediastinum and pneumoperitoneum were managed conservatively. Discussion Mechanical ventilation in patients with pneumothorax and subcutaneous emphysema carries a significant risk of exacerbating both conditions. We utilized a strategy of low tidal volume ventilation, specifically 4-6ml of Predicted Body Weight . Additionally, adjustments to Positive End-Expiratory Pressure (PEEP) were coupled with serial chest imaging to assess the extent of the pneumothorax along with repeated monitoring of chest tube output to ensure effective removal of excess air, thereby mitigating further harm and ensuring adequate oxygenation. Furthermore, neuromuscular blockade can promote lung-protective ventilation by enhancing synchrony, reducing forceful spontaneous breathing, and thus lowering peak and plateau pressures as well as associated driving pressures which correlate with a reduced risk of barotrauma. Conclusion High suspicion and early imaging are essential for the quick identification of lung problems exacerbated by barotrauma. Lung-protective ventilation, low pressures, and frequent imaging and monitoring may help reduce poor outcomes. This abstract is funded by: None