A33-37 When the Guidelines Whisper “Tracheostomy” ⋯ Think Twice

Abstract Introduction Status asthmaticus is a life-threatening exacerbation of asthma which fails to respond to standard therapy - characterized by respiratory failure, often requiring prolonged mechanical ventilation. Mechanical ventilation even though lifesaving has several risks including dynamic hyperinflation, barotrauma, and airway edema leading to obstruction. The cuff-leak test is often used to predict post-extubation obstruction and guide tracheostomy decisions, though its predictive value is imperfect. We present a case of refractory status asthmaticus successfully extubated despite an absent cuff leak. Case Presentation A 27-year-old woman with a history of asthma and multiple hospitalizations arrived at the emergency department struggling to breathe, with wheezing and chest tightness triggered by a rhinovirus infection. Despite aggressive therapy—including nebulized bronchodilators, intravenous corticosteroids, and magnesium sulfate—she developed respiratory failure requiring BiPAP and subsequent intubation. Assist-control volume ventilation (6-8 cc/kg ideal body weight) was initiated, but persistent ventilator dyssynchrony, elevated peak pressures necessitated neuromuscular blockade, permissive hypercapnia, heliox, and high-dose steroids. The hospital course was complicated by pneumomediastinum and subcutaneous emphysema . By day 13, she showed clinical improvement and tolerated spontaneous breathing trials. However, repeated failure of the cuff-leak test raised concern for airway edema. Racemic epinephrine was initiated, and tracheostomy was considered. A multidisciplinary decision was made to attempt controlled extubation in the operating room with surgical backup. She was successfully extubated without airway compromise. Mild dysphonia resolved spontaneously, and imaging confirmed resolution of soft-tissue emphysema. She was transitioned to oral steroids, weaned to room air, and discharged with outpatient pulmonary follow-up. Discussion Severe status asthmaticus often necessitates prolonged mechanical ventilation, which increases the risk of airway complications and challenges of extubation planning. While guidelines recommend tracheostomy after 7-14 days of intubation, the absence of a cuff leak may reflect reversible edema rather than fixed obstruction. In this case, individualized assessment and multidisciplinary coordination enabled safe extubation despite guideline-based indications for tracheostomy. Her quick recovery and resolution of complications show that clinical judgment and teamwork can guide safe extubation decisions, even when standard tests suggest otherwise. This case supports a flexible, patient-centered approach to airway management in severe asthma. Conclusion Severe asthma exacerbations requiring prolonged ventilation can defy expectations. This case advocates for cautious optimism and individualized management, as timely extubation may avert tracheostomy even after 14 days of intubation. This abstract is funded by: None