Pulmonary Barotrauma Including Huge Pulmonary Interstitial Emphysema in an Adult with Status Asthmaticus: Diagnostic and Therapeutic Challenges

INTRODUCTION: Pulmonary interstitial emphysema is a rare finding defined as abnormal air collection inside the lung interstitial tissues. Described more frequently in ventilated new-borns, pulmonary interstitial emphysema is an uncommon barotrauma-related complication in adults. Management and clinical sequelae are poorly described. PATIENT: We describe the case of a 64-year-old man who presented with huge pulmonary interstitial emphysema together with simultaneous pulmonary barotrauma in status asthmaticus requiring invasive ventilation. DISCUSSION: There are no guidelines for the management of such complications and their possible sequelae but conservative treatment seems to be effective. The treatment of our patient is described. LEARNING POINTS: We describe ventilation-induced tension pulmonary interstitial emphysema combined with contralateral pneumothorax, pneumomediastinum, pneumoperitoneum and subcutaneous emphysema which developed immediately after difficult airway management of acutely decompensated asthma in an adult. The present case highlights the importance of crash induction, cautious airway management and protective re-ventilation in the management of acute respiratory failure with dynamic hyperinflation, such as status asthmaticus. Minimally invasive management by percutaneous trans-thoracic intrabullous chest-tube drainage is feasible, safe and relatively effective.