Abstract Introduction Barotrauma such as pneumothorax is a common complication of severe asthma exacerbations, that poses a contraindication to mechanical ventilation as a stand-alone therapy. Heliox, is an adjunctive treatment in patients with status asthmaticus rarely used in practice. This case highlights a unique application of heliox as an effective alternative treatment in a patient affected by severe barotrauma. Case Report A 29-year-old male with a history of asthma and prior intubation presented with progressively worsening shortness of breath and cough refractory to inhaled bronchodilator therapy. Due to tachypnea and increased work of breathing on nasal cannula, the patient was started on BiPAP. Respiratory viral panel was positive for rhinovirus. Chest radiograph demonstrated pneumomediastinum, possible pneumothorax, and diffuse subcutaneous emphysema. Computed tomography scan of the chest confirmed these findings and demonstrated large-volume air along the anterior and basilar heart, consistent with pneumopericardium. No right heart strain was identified on echocardiogram. BiPAP was discontinued. The patient was started on heliox therapy, high-flow nasal cannula, and a dexmedetomidine infusion for anxiety. Cardiothoracic surgery recommended close monitoring. Empiric antibiotics and IV solumedrol were started. The patient clinically improved and was weaned off oxygen, eventually being discharged after four days with outpatient follow-up. Discussion Life-threatening bronchospasm in an asthmatic patient that persists despite bronchodilator or corticosteroid therapy, is defined as status asthmaticus. It is estimated that as many as 13-16% of these patients require ventilatory support—an intervention proven to be the single greatest predictor of death from asthma. With pneumothorax being a well known common complication. The combination of pneumomediastinum, pneumopericardium, and pneumothorax in the setting of mechanical ventilation, is unique to this case, and presents a unique indication to the use of heliox. Heliox therapy is useful in patients with upper respiratory tract obstruction, from either a mechanical obstruction or reactive airway disease such as asthma or COPD. The relatively low density of helium, in combination with oxygen, allows the delivery of higher quantities of oxygen to the alveoli through reductions in upper airway resistance and anatomical dead space. This approach has previously been studied in patients with asthma exacerbations who were not mechanically ventilated, with current evidence demonstrating an overall lower efficacy of heliox therapy compared to the current standard of care. However, given the extent of barotrauma in our patient posing a contraindication to pressure-based mechanical ventilation as a stand-alone therapy, heliox was utilized as an effective alternative in this case. This abstract is funded by: none
Saraf et al. (Fri,) studied this question.