C52-13 Severe Asthma Exacerbation Complicated by Subcutaneous Emphysema, Pneumomediastinum, and Pneumothorax: A Case Report Highlighting Ventilatory Challenges

Abstract Introduction Severe asthma exacerbations in young adults can present unique challenges, including complications such as barotrauma often requiring careful management to avoid further iatrogenic injury. Risk factors include aggressive ventilatory strategies used to manage their acute exacerbations, combined with their greater physiological capacity to generate high intrathoracic pressures, which predisposes them to barotrauma. Here, a case is described of a young female admitted for an asthma exacerbation requiring intubation complicated by pneumothorax, subcutaneous emphysema, pneumomediastinum, and cardiac arrest. Case Presentation A 23-year-old female with asthma (adherent to treatment) and an active smoking history presented with a three-day history of productive cough, shortness of breath, rhinorrhea, and wheezing. She had prior ICU admissions but had never been intubated. Despite albuterol and inhaled corticosteroid-formoterol therapy, her symptoms worsened. On arrival, she had tachypnea with an oxygen saturation of 80%. Venous blood gas showed lactate 4.8 mmol/L, pH 7.28, and pCO2 50 mmHg. She tested positive for rhinovirus. She received oxygen, nebulized albuterol-ipratropium, systemic corticosteroids, and IV magnesium sulfate without improvement. Non-invasive ventilation (NIV) with bilevel positive airway pressure led to initial improvement (pH 7.33, pCO2 40). She then became anxious, tripoded, and became asynchronous on NIV. Subcutaneous crepitus was noted over the chest and neck, and imaging confirmed subcutaneous emphysema with pneumomediastinum (image below). Blood gas showed pH 7.32, pCO2 45. She was intubated due to worsening respiratory distress. Fentanyl, propofol, and ketamine were used to maintain ventilator synchrony, and Positive End Expiratory Pressure (PEEP) was minimized. Despite this, she developed ventilator dyssnchrony with peak pressures of 70-80 cm H2O and plateau pressures rising from 20 to 30 cm H2O. Repeat blood gas showed worsening acidosis (pH 7.11, pCO2 77). She was transferred for ECMO due to the concern of evolving ARDS. Her course was complicated by tension pneumothorax requiring bilateral chest tubes, followed by hemothorax and a cardiac arrest. She was later extubated, underwent tracheostomy, was successfully decannulated, and was discharged. Case Discussion This case highlights asthma complications that contribute to increased morbidity and prolonged hospitalization. Subcutaneous emphysema, pneumothorax, and pneumomediastinum can occur in this setting, requiring careful ventilatory management and consideration of advanced therapies to avoid further iatrogenic injury. Anxiety can worsen dyspnea and impair ventilator synchrony, underscoring the need for approach sedation and anxiolysis. These complications reinforce the importance of lung-protective ventilation strategies and early consideration of alternative therapies, such as ECMO, in vulnerable patients. This abstract is funded by: None