A 16-year-old woman with a history of poorly controlled asthma and a particular use of hookah was admitted to the emergency room of Hospital Irmandade da Santa Casa de Misericordia, Sorocaba, São Paulo, Brazil on March 24th, 2023.

Seven days before admission, she had used hookah at a party with friends and then she started with a discrete wheezing that got worse in the following days. She started oral prednisone and salbutamol as needed. Due to the persistence of symptoms and limitation to daily activities, she went to the emergency room.

After admission, methylprednisolone 40 mg/day, ceftriaxone and azithromycin were started. Despite initial treatment she didn`t improve and started the use of high flow oxygen. She was transferred to the intensive care unit on March 25th and was intubated and mechanically ventilated due to refractory bronchospasm and worsening of hypoxia.

After optimization of bronchodilators and inhaled corticosteroids, protective ventilation was initiated with neuromuscular blockade. Due to persistent hypoxemia, prone position was initiated without improvement of hypoxemia (PaO2/FIO2 =75.6) and hypercapnia (PaCO2 = 117.5 mmHg). Because of the clinical refractoriness, on April 6th, 2023, the case was discussed with the ECMO team at INCOR Institute and veno-venous cannulation with extracorporeal support was indicated as a ransom measure for both hypoxemia and hypercapnia.

A specialized ECMO team composed of two pulmonologists, three thoracic surgeons and two perfusionists traveled from São Paulo (capital of the state of São Paulo) to Sorocaba (state of São Paulo) to cannulate the patient at the hospital of origin (figure 1) and bring her by ambulance to the INCOR reference center of ECMO to continue her treatment.