(729) Extracorporeal Support for Spontaneous Pneumomediastinum Secondary to Viral Infection in a Child

Introduction: Spontaneous pneumomediastinum (SPM) is a rare in respiratory tract infections in children. We report a case of SPM secondary to respiratory syncytial viral (RSV) infection that was managed with veno-venous extracorporeal membrane oxygenation (VV-ECMO) in a pediatric patient.

Description: A 2-year-old girl with previous history of uneventful hospital admissions for viral respiratory tract infections was admitted for acute respiratory distress secondary to RSV infection. She had unremarkable chest x-ray and did not respond to home albuterol and prednisolone. She was tachypneic (RR: 29/min), hypoxic (O2 sats: 86-88%) with coarse breath sounds bilaterally. She was initiated on albuterol therapy, intravenous fluids, and face mask O2 therapy. 2 days later she had a coughing spell associated with O2 saturation of 60% prompting chest x-ray that revealed bilateral multi-lobar atelectasis with development of pneumomediastinum and subcutaneous emphysema. She was placed on high flow nasal cannula and 100% O2 for hypoxemia that continued to worsen over the next 12 hours (O2 sats: 82-85%). She was intubated and placed on mechanical ventilation, prone position, inhaled nitric oxide, methylprednisolone, and continuous albuterol therapy. She continued to demonstrate worsening pneumomediastinum and subcutaneous emphysema, and increasing hypoxemia (Oxygenation index: 45). She was placed on VV-ECMO via dual lumen catheter in the right internal jugular vein at 90 ml/kg/min. On VV-ECMO, she was supported with very low ventilator settings and her air-leak syndrome gradually resolved. VV-ECMO was discontinued after 11 days; she was extubated to non-invasive ventilation after 15 days and discharged home after 28 days on 1 L/min nasal cannula O2, and inhaled steroid therapy. There is no recurrence of air-leak on 6 months follow-up.

Discussion: SPM is typically a benign condition that resolves within 3-15 days with supportive care. Limited treatment options exist for progressive SPM. Extracorporeal support facilitates usage of low ventilator settings to prevent further alveolar injury, allow air leak to seal and simultaneously provide adequate gas exchange as seen in our patient. Thus, extracorporeal support maybe an option to manage SPM due to viral infections that fail to resolve with conservative approach.