Pneumomediastinum in Acute Asthma Exacerbation

Pneumomediastinum (PM) is a rare but significant complication of asthma exacerbation. We present the case of a 57-year-old woman with a history of asthma and alcoholic liver cirrhosis who presented to the ED with severe shortness of breath and an oxygen saturation of 83% on room air, as reported by EMS. On arrival, she was tachycardic and hypoxic, requiring 5 L/min of oxygen via nebulizer mask, with diffuse wheezing noted on auscultation. Despite aggressive medical management, including high-flow oxygen, bronchodilators, and steroids, her symptoms persisted. A chest radiograph was unremarkable; however, a CT scan of the chest revealed air tracking along the anterior mediastinum without evidence of pneumothorax. Given her clinical stability and the absence of esophageal injury on fluoroscopy, she was managed conservatively with close observation. Repeat imaging demonstrated resolution of the PM without surgical intervention. The patient was hospitalized for 19 days and discharged in stable condition with normal vital signs, with outpatient follow-up arranged with her primary care physician and pulmonologist. This case highlights the importance of considering PM in the differential diagnosis of patients with refractory asthma exacerbations, particularly in older adults, despite its more frequent association with pediatric and trauma populations. Early imaging in non-responding asthma patients may facilitate timely diagnosis and appropriate management.