A multidisciplinary approach to prolonged extracorporeal membrane oxygenation for acute respiratory distress syndrome due to coronavirus 2019-case report

Abstract

Patients with novel coronavirus 2019 (COVID-19) may develop acute respiratory distress syndrome (ARDS) and require extracorporeal membrane oxygenation (ECMO) support. Currently there is no specific treatment for COVID-19 available; thus, for patients with severe ARDS, the respiratory condition needs to improve while on ECMO support. Here we present a multidisciplinary team approach to the care of a patient with COVID-related ARDS requiring three months of veno-venous (VV) ECMO which lead to recovery. A 35-year-old male was transferred to us with ARDS due to COVID-19 infection with a lactate 13.7 mmol/L and an arterial-blood gas oxygenation of 75 mmHg on maximum ventilator settings. He was placed on VV ECMO during which he developed pneumonia, bacteremia, and pneumothoraces; however, his other organ functions were preserved. During his time in the Intensive Care Unit (ICU), multiple subspecialist teams participated in his care including physicians, pharmacists, nurses, nutritionists, case management, and social work. The VV ECMO was weaned off after 91 days of support, after which he had a prolonged hospital course due to inflammatory bowel disease, and aspiration pneumonia. CT scan performed six weeks prior to discharge showed mild improvement in diffuse airspace opacities superimposed on extensive chronic cystic changes. He was eventually discharged to a rehabilitation facility 68 days after ECMO removal. He was then seen in our outpatient pulmonary clinic one month and our Post-Intensive Care Syndrome clinic three months after discharge on two liters of nasal cannula oxygen. Pulmonary function testing done at this time demonstrated severe restrictive lung disease and severely reduced diffusion capacity. This case highlights the need for multidisciplinary collaboration among hospital teams to ensure success and patient survival in the setting of COVID ARDS. In those COVID ARDS patients with intact renal, metabolic, hematologic, and cardiovascular function, ECMO should be strongly considered.

Keywords: Acute respiratory distress syndrome (ARDS); case report; extracorporeal membrane oxygenation (ECMO); novel coronavirus 2019 (COVID-19).

Figure 1

Chest X-ray images throughout admission. (A) X-ray on admission (05/02/2020); (B) X-ray after ECMO cannulation (05/03/2020); (C) X-ray during ECMO course (05/20/2020); (D) X-ray after ECMO decannulation (08/02/2020); (E) X-ray prior to discharge (10/02/2020). ECMO, extracorporeal membrane oxygenation.

Figure 2

CT chest images throughout admission. (A) CT on admission (05/02/2020); (B,C) CT during ECMO (06/06/2020); (D) CT during ECMO (06/29/2020); (E) post decannulation (08/23/2020). ECMO, extracorporeal membrane oxygenation.

Figure 3

FiO₂ on ventilator and ECMO, sweep, aligned with timeline of epoprostenol (green), paralytics (blue), antibiotics (red) and cultures. Kleb, Klebsiella pneumoniae; E. Coli, Escherichia coli; E. Faec, Enterococcus faecalis; ECMO, extracorporeal membrane oxygenation.

Figure 4

Pulmonary function testing and flow/volume curve after hospital discharge. (A) Pulmonary function testing results; (B) flow/volume curve.