BILATERAL PNEUMOTHORAX, PNEUMOMEDIASTINUM, AND SUBCUTANEOUS EMPHYSEMA: A CASE OF A RARE SYNCHRONOUS TRIAD IN ASTHMA EXACERBATION

ABSTRACT

SESSION TITLE Obstructive Lung Disease Case Report Posters SESSION TYPE Case Report Posters PRESENTED ON 10/17/2022 1215 pm - 0115 pm INTRODUCTION: Individual cases of pneumothorax, pneumomediastinum and subcutaneous emphysema have been reported in asthma attacks, but rarely coincide. Pathophysiology is secondary to obstruction in the minor airways leading to air-trapping and barotrauma of distal airways with subsequent alveolar rupture. This case illustrates a case of asthma exacerbation with a synchronous triad of rare complications. CASE PRESENTATION 65-year-old female with a history of breast cancer, asthma and hypertension presented with shortness of breath, wheezing, and productive cough since four days ago. Vital signs were remarkable for tachypnea and saturation of 91%. Physical examination revealed respiratory distress, and auscultation disclosed diffuse inspiratory and expiratory wheezing. Limited bedside ultrasound showed B-lines compatible for pulmonary edema. Arterial blood gases were compatible with respiratory acidosis and hypoxemia. Laboratories showed leukocytosis, hypotonic hyponatremia, normal brain natriuretic peptide, and negative COVID-19 PCR test. Chest Xray (CXR) demonstrated changes concerning for pneumonia with superimposed pleural effusion. The patient was admitted with the impression of asthma exacerbation versus community acquired pneumonia. Initially, the patient was placed in bi-level positive airway pressure to aid in respiratory discomfort, broad spectrum antibiotic regimen, and diuresis therapy. On follow up, she was found hypoxic with periorbital edema, dyspnea, and subcutaneous emphysema in neck, upper extremities, and thorax for which emergent intubation was performed. CXR and Thoracic CT confirmed pneumomediastinum, large right sided pneumothorax and a moderate left sided pneumothorax requiring tube thoracostomy. At the Intensive Care Unit, treatment included combination therapies with levalbuterol, ipratropium, terbutaline, theophylline, budesonide, IV steroids and magnesium without appropriate response. Mechanical ventilator was set to protective lung parameters to avoid worsening barotrauma. Subsequently, she was paralyzed for 48 hours to aid in synchrony and allow adequate pulmonary gas exchange. Nonetheless, severe bronchoconstriction was persistent along with depressed neurological status. Two months later, the patient passed away. DISCUSSION: We believe our patient developed barotrauma secondary to a cough attack combined with positive airway pressure. Similarities in presentation such as dyspnea, tachycardia, and hypoxia may prove difficult in differentiation. Although each of these pathologies separately can generally be self-limiting depending on size and hemodynamic compromise, the combination can be mortal and clinical suspicion is important in fast diagnosis and treatment. CONCLUSIONS: Our case demonstrates the importance of suspicion of barotrauma in patients with asthma attacks not responding adequately to therapy or developing worsening hypoxia which can be detrimental. Reference #1 Franco, A. I., Arponen, S., Hermoso, F., & García, M. J. (2019). Subcutaneous emphysema, pneumothorax and pneumomediastinum as a complication of an asthma attack. The Indian journal of radiology & imaging, 29(1), 77–80. https//doi.org/10.4103/ijri.IJRI_340_18 Reference #2 Zeynep Karakaya, Şerafettin Demir, Sönmez Serkan Sagay, Olcay Karakaya, Serife Özdinç, "Bilateral Spontaneous Pneumothorax, Pneumomediastinum, and Subcutaneous Emphysema Rare and Fatal Complications of Asthma", Case Reports in Emergency Medicine, vol. 2012, Article ID 242579, 3 pages, 2012.https//doi.org/10.1155/2012/242579 Reference #3 Subcutaneous Emphysema in Acute Asthma A Cause for Concern? Patrick D Mitchell, Thomas J King, Donal B O'Shea Respiratory Care Aug 2015, 60 (8) e141-e143;DOI 10.4187/respcare.03750 DISCLOSURES No relevant relationships by Juan Adams-Chahin No relevant relationships by Gretchen Marrero No relevant relationships by natalia Mestres No relevant relationships by Are is Morales Malavé No relevant relationships by Carlos Sifre No relevant relationships by Paloma Velasco No relevant relationships by Mark Vergara-Gomez