A52-08 Veno-Venous ECMO as Rescue Therapy for Refractory Hypercapnia in an Immunocompromised Patient

Abstract Background Status asthmaticus may lead to life-threatening ventilator-refractory hypercapnic respiratory failure due to severe dynamic hyperinflation and airflow obstruction. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) provides extracorporeal CO2 clearance and lung rest in refractory cases. Evidence in immunocompromised patients, particularly those with uncontrolled HIV infection, remains limited. Case A 31-year-old woman with childhood-onset asthma, untreated HIV (CD4 158), and tobacco use presented with acute dyspnea, chest tightness, and wheezing following a viral prodrome. Despite initial management with bronchodilators, epinephrine, methylprednisolone, and magnesium, she developed worsening respiratory distress requiring noninvasive positive-pressure ventilation (NIPPV). Venous blood gas showed pH 7.28, PCO2 56 mmHg, and PO2 47 mmHg. The respiratory viral panel was positive for rhinovirus, and sputum culture grew Haemophilus influenzae. After intubation, she exhibited severe ventilator dyssynchrony and refractory hypercapnia (PCO2 75 mmHg) despite paralysis and optimized mechanical ventilation. VV-ECMO was initiated via right internal jugular and femoral cannulation for extracorporeal CO2 removal and lung rest. Intervention and Outcome VV-ECMO was initiated with 2,500 RPM, flow 3.0 L/min, and blender FiO2 1.0. Anticoagulation followed institutional protocol. She received ceftriaxone for H. influenzae and trimethoprim-sulfamethoxazole for Pneumocystis prophylaxis. PaCO2 improved to the 60s by ECMO day 2, and the patient was decannulated by day 4 and extubated by day 5 with full recovery. She was discharged with controller inhaler therapy, a prednisone taper, and outpatient follow-up for asthma management and HIV care. Discussion VV-ECMO provided effective CO2 clearance and lung rest in a patient with status asthmaticus refractory to maximal medical therapy. This case illustrates that immunocompromised status, including untreated HIV, should be viewed as a relative—not absolute—contraindication when the underlying process is reversible. Early multidisciplinary evaluation and ECMO initiation can be lifesaving in such scenarios. Conclusion VV-ECMO can serve as a bridge to recovery for refractory hypercapnic respiratory failure in status asthmaticus, even in immunocompromised hosts. Careful patient selection and coordinated multidisciplinary management are key to successful outcomes. This abstract is funded by: None