C48-48 When Obstruction Meets Restriction: Rescue VV-ECMO for Refractory Status Asthmaticus Evolving Into ARDS in a Young Adult

Abstract Background Status asthmaticus is a life-threatening asthma exacerbation unresponsive to maximal medical therapy. Mechanical ventilation may worsen dynamic hyperinflation, hypercapnia, and barotrauma. Secondary infection or ventilator stress can shift physiology toward ARDS, leading to mixed obstructive-restrictive failure. ECMO is rarely used in asthma (2% of ELSO cases) but has high survival in reversible etiologies. This case highlights early recognition of evolving physiology and timely VV-ECMO activation in a young adult with in-flight collapse. Case Presentation A 19-year-old woman with a history of asthma developed severe dyspnea during a long-haul flight. In the ED, she was in severe distress and required emergent intubation (ABG 7.21/60/405). Initial volume-controlled ventilation (FiO2 100%, PEEP 5, TV 500 mL, RR 15) was complicated by peak pressures 45 cmH2O, prompting deep sedation, neuromuscular blockade, and ketamine for bronchodilation. Despite aggressive bronchodilator therapy and corticosteroids, she developed worsening oxygenation with new bilateral infiltrates from MSSA and H. influenzae pneumonia, consistent with evolving ARDS. Ventilation was transitioned to lung-protective strategy (TV 400 mL, PEEP 18, RR 18), reducing plateau pressure from 37→32 cmH2O (driving pressure 14). However, hypoxemia persisted (ABG 7.48/59/73 on FiO2 100%, PF ratio ∼70). Bronchoscopy demonstrated patent airways without mucus plugging, supporting parenchymal rather than obstructive failure. Given refractory hypoxemia and rising ventilator pressures, the ECMO team was consulted. The patient underwent bedside veno-venous ECMO cannulation and stabilized prior to transfer to a tertiary ECMO center. Discussion This case demonstrates the transition from obstructive status asthmaticus to ARDS with restrictive physiology, requiring ventilator strategy adjustment and timely ECMO referral. Lung-protective ventilation with permissive hypercapnia is essential, but severe acidosis or injurious airway pressures indicate need for extracorporeal support. Early bronchoscopy is critical to differentiate mucus obstruction from intrinsic lung disease, informing escalation decisions. VV-ECMO provides gas exchange while allowing lung rest, reducing risk of ventilator-induced lung injury. Conclusion Refractory asthma can progress into ARDS; recognizing this shift and consulting ECMO early may prevent catastrophic deterioration. VV-ECMO serves as a bridge to recovery in reversible respiratory failure. References Papiris SA et al. Crit Care. 2002. Laffey JG, Kavanagh BP. N Engl J Med. 2002. Papazian L et al. Am J Respir Crit Care Med. 2020. ELSO Adult Respiratory Failure Guidelines. 2022. This abstract is funded by: None