Lung Recovery After Long Venovenous Extracorporeal Membrane Oxygenation Support for COVID-19 Acute Respiratory Failure: A Case Report

Abstract

Introduction: Venovenous (VV) Extracorporeal Membrane Oxygenation (ECMO) is an effective rescue therapy for coronavirus disease 2019 (COVID-19)- acute respiratory failure. However, the optimal duration of ECMO support and time to lung recovery remain unknown. Description: A 48-year-old Hispanic male without significant past medical history was transferred to a tertiary care high-volume ECMO center on mechanical ventilation after 11 days of progressive shortness of breath due to COVID-19 pneumonia. He was transferred heavily sedated, paralyzed, in the prone position, and with lung protective mechanical ventilation settings of 6cc/kg of ideal body weight, tidal volume of 350cc, positive end-expiratory pressure of 14 cm H2O, respiratory rate of 30 breaths per minute, and FiO2 of 100%. His driving and plateau pressures were 13 and 27 cm H2O, respectively. Three days after intubation, his PO2/FiO2 ratio repeatedly dropped below 80 and he was placed on Vf -Vj ECMO for severe acute respiratory distress syndrome (ARDS). During his ICU course, the patient received adjunctive therapies, including Remdesivir and Dexamethasone. He was extremely encephalopathic, resulting in a failed trial of extubation and requiring tracheostomy placement 14 days after intubation. His ECMO run was complicated by oxygenator failure and emergent exchange of ECMO circuit despite anticoagulation with bivalirudin. His course was complicated by superimposed Enterobacter pneumonia and he was treated with antibiotics. After 38 days of VV ECMO support, he showed improvement in compliance and gas exchange, indicating lung recovery. The patient was weaned successfully from ECMO and remained on mechanical ventilation for almost 30 days after decannulation. The ICU team carried out aggressive physical therapy, the patient was weaned off mechanical ventilation, his tracheostomy was decannulated, and he was discharged on 2L O2. CT at the time of discharge showed “improved aeration of both lungs” with residual lung fibrosis and bronchiectasis (Figure 1). Discussion: ARDS remains the most common indication for long-term ECMO support, which is frequently complicated by severe deconditioning, secondary infection, and vascular complications. In a stratified analysis of 127 patients who received ECMO support for respiratory failure, patient survival was 52% after being on ECMO for more than 20 days.1 Despite multiple complications, including superimposed infection and oxygenator failure, our patient showed recovery from his ARDS. He was eventually extubated and discharged from the hospital, indicating ECMO as an effective treatment for COVID-19 pneumonia. VV ECMO support for COVID-19 pneumonia should be considered for all eligible patients as infection rates and continue to rise.