LAUSR

Introduction: Massive subcutaneous emphysema (SE) from pneumomediastinum can be disfiguring and uncomfortable, especially with persistent air leak in acute respiratory distress syndrome (ARDS). Consensus is lacking on safe and efficacious methods to decompress SE as it is typically managed conservatively unless airway or cardiovascular compromise occurs. Treatment in children is less well described, especially at the end of life. Description: A 6 year-old male with multiply relapsed leukemia was admitted with ARDS requiring intubation secondary to polymicrobial gram-negative sepsis and adenoviral pneumonia. Despite lung-protective ventilator strategies and adequate analgesia and sedation, he had an episode of coughing resulting in small bilateral pneumothoraces and pneumomediastinum with subsequent development of SE. Initially limited to the neck and chest, it spread to the scalp, face, arms, abdomen, groin, and thighs despite ventilator adjustments and changes in delivery modes to limit intrathoracic pressure. He required escalating sedation and analgesia due to discomfort from continual expansion of the SE. Given his active multiply relapsed cancer, extracorporeal support was not offered, and he was redirected to comfort care. His parents’ only desire was to alleviate his extreme disfiguration and hold him without causing further discomfort or trauma. He underwent palliative bedside placement of bilateral infraclavicular subcutaneous drains with vacuumassisted closure (VAC) to continuous suction accompanied by manual expression of the accumulated air. There was immediate and nearly complete resolution of the SE with improvement in the patient’s agitation and appearance, allowing the family to comfortably interact with him. Though the air leak persisted, the SE did not reaccumulate. He developed a large right pneumothorax two days after with avoidance of tension physiology and imminent death due to drainage via the VAC permitting a compassionate terminal extubation the following day once extended family gathered at the bedside. Discussion: Massive SE can be physically and psychologically distressing. Evacuation of SE is safe at the bedside using subcutaneous VAC therapy with rapid symptom improvement. Our experience describes the first use as a pediatric palliative endof-life procedure.