Near fatal asthma, challenges of management with coexisting pneumothorax

Near-fatal asthma (NFA) is a life-threatening condition often requiring ventilatory support. The coexistence of pneumonia as a precipitating element for NFA with pneumothorax and pneumomediastinum presents significant diagnostic and therapeutic challenges. We report a 28-year-old woman with known bronchial asthma who presented with severe respiratory distress following upper respiratory tract infection symptoms. She was hypoxemic with clinical evidence of severe asthma exacerbation and subcutaneous emphysema. Imaging demonstrated left upper lobe pneumonia and pneumomediastinum, with subsequent development of a large left-sided pneumothorax. Despite aggressive medical therapy, she required tracheal intubation and chest tube insertion. Management included lung-protective ventilation, meticulous management of ventilator settings, measures to reduce airway resistance and inflammation along with broad-spectrum antibiotics and systemic corticosteroids. The patient improved clinically and radiologically, was successfully extubated, and discharged in stable condition. This case highlights the complex interplay between infection, airway inflammation, and spontaneous barotrauma, emphasizing the importance of early recognition and individualized ventilatory strategies to optimize the outcome.