Reversibility of total airway closure and alveolar consolidation in a COVID-19 patient: A case study

Abstract

Coronavirus disease 2019 (COVID-19) may be complicated by life-threatening pneumonia requiring tracheal intubation, mechanical ventilation and veno-venous extracorporeal membrane oxygenation (vvECMO). It is not yet clear to what extent and after which delay the most severe cases of COVID-19 pneumonia are reversible. Here, we present a 39-year-old patient who developed a severe COVID-19-attributed acute respiratory distress syndrome (ARDS) resulting in complete alveolar consolidation and airway closure for several weeks. His remarkable ventilatory pattern was established using ventilator airway pressure curve analysis and computed tomography imaging. The patient was managed with supportive care, mechanical ventilation and vvECMO. He received dexamethasone and tocilizumab as immunomodulatory drugs. Despite multiple complications, he recovered and was weaned from vvECMO, ventilator and oxygen on days 75, 95 and 99 post-intubation, respectively. He was discharged from hospital on day 113. This case study strongly supports the remarkable potential for reversibility of ARDS in COVID-19 patients and discusses the implications for critical care nursing regarding mechanical ventilation and ECMO device management in patients who may become entirely dependent on vvECMO for oxygenation and carbon dioxide elimination.

Keywords: ARDS; COVID-19; ECMO; airway closure; alveolar consolidation; case study; outcome.

FIGURE 1

Pulmonary compliance during veno‐venous extracorporeal membrane oxygenation (vvECMO) treatment showing improvement starting on day 42 post‐intubation (day 38 of vvECMO) (A). Airway pressure curve on day 19 post‐intubation with time as horizontal axis showing a straight line reaching airway pressure of 51 cmH₂O and driving pressure of 46 cmH₂O with a 5 L/min insufflation rate (inspiratory output) and at a positive end‐expiratory pressure of 5 cmH₂O (B). Pulmonary compliance calculated at 1.5 mL/cmH₂O was in favour of complete airway closure that persisted ~35 days before improvement

FIGURE 2

Computed tomography scan below the carina showing air bronchogram (short arrows) and some aerated alveoli (long arrows) as well as a fine partially drained pneumothorax (arrowhead) on day 6 of veno‐venous extracorporeal membrane oxygenation (vvECMO) (A). On day 15 of vvECMO the computed tomography showed total absence of air in the airways and alveoli (B) and the chest X‐ray on the same day showed complete absence of air (C). On day 20 after weaning from vvECMO and weaning from ventilator and oxygen, the chest X‐ray showed complete re‐aeration of the lungs (D). Embolization of three intercostal arteries and pleural surgery were necessary to stop extensive haemothorax and evacuate the residual haemorrhagic collection. Chest drain (panels A, B and C), orogastric tube (panels A, B and C), ECMO cannula (panels A and B), embolization coils (panel D) and tracheotomy cannula (panel D) are visible in the figure