Bilateral Pneumothorax and Subcutaneous Emphysema as a Complication of Mechanical Ventilation in Pediatric Status Epilepticus: A Case Report

Abstract

Status epilepticus (SE) is a life-threatening neurological emergency requiring rapid pharmacological intervention and often advanced airway management. While mechanical ventilation is frequently necessary to protect the airway and ensure adequate oxygenation during continuous sedation, it carries inherent risks, including ventilator-induced pulmonary barotrauma. Pneumothorax and subcutaneous emphysema are known, albeit rare, severe complications in this setting. This case report details the development and management of bilateral pneumothorax and extensive subcutaneous emphysema in a pediatric patient intubated for the onset refractory status epilepticus. A 16-year-old female with a previously known case of seizure disorder presented to the emergency department with new-onset generalized tonic–clonic status epilepticus. Initial management with first-line and second-line antiepileptic drugs, including lorazepam, phenytoin, and levetiracetam, failed to terminate the seizure activity. A midazolam infusion was initiated, and the patient was conservatively intubated due to persistent seizures and progressive respiratory compromise. Within 24 h postintubation, the patient developed marked subcutaneous emphysema and sudden respiratory decompensation. A chest radiograph and high-resolution computed tomography of the chest confirmed bilateral pneumothoraces. The patient was successfully managed with the insertion of bilateral intercostal drains (ICDs) and conservative ventilatory weaning. Following the resolution of the pneumothoraces and cessation of seizures, the ICDs were removed, and the patient was discharged in a stable condition with outpatient neurology follow-up. This case highlights the critical need for vigilance regarding pulmonary barotrauma in pediatric patients receiving mechanical ventilation for status epilepticus. It underscores the importance of utilizing lung-protective ventilation strategies and prompt interventional management, such as ICD insertion, to mitigate life-threatening pulmonary complications while simultaneously addressing the underlying neurological emergency.