Venovenous Extracorporeal Membrane Oxygenation in Awake Non-Intubated Patients With COVID-19 ARDS at High Risk for Barotrauma

Abstract

Objectives: To assess the efficacy of an awake venovenous extracorporeal membrane oxygenation (VV-ECMO) management strategy in preventing clinically relevant barotrauma in patients with coronavirus disease 2019 (COVID-19) with severe acute respiratory distress syndrome (ARDS) at high risk for pneumothorax (PNX)/pneumomediastinum (PMD), defined as the detection of the Macklin-like effect on chest computed tomography (CT) scan.

Design: A case series.

Setting: At the intensive care unit of a tertiary-care institution.

Participants: Seven patients with COVID-19-associated severe ARDS and Macklin-like radiologic sign on baseline chest CT.

Interventions: Primary VV-ECMO under spontaneous breathing instead of invasive mechanical ventilation (IMV). All patients received noninvasive ventilation or oxygen through a high-flow nasal cannula before and during ECMO support. The study authors collected data on cannulation strategy, clinical management, and outcome. Failure of awake VV-ECMO strategy was defined as the need for IMV due to worsening respiratory failure or delirium/agitation. The primary outcome was the development of PNX/PMD.

Measurements and main results: No patient developed PNX/PMD. The awake VV-ECMO strategy failed in 1 patient (14.3%). Severe complications were observed in 4 (57.1%) patients and were noted as the following: intracranial bleeding in 1 patient (14.3%), septic shock in 2 patients (28.6%), and secondary pulmonary infections in 3 patients (42.8%). Two patients died (28.6%), whereas 5 were successfully weaned off VV-ECMO and were discharged home.

Conclusions: VV-ECMO in awake and spontaneously breathing patients with severe COVID-19 ARDS may be a feasible and safe strategy to prevent the development of PNX/PMD in patients at high risk for this complication.

Keywords: COVID-19; Macklin effect; acute respiratory distress syndrome; barotrauma; extracorporeal membrane oxygenation; mechanical ventilation.

Graphical abstract

Fig 1

Macklin-like radiologic sign on lung parenchyma window chest computed tomography scans (red arrows). (A) A crescent collection of air contiguous to the right main bronchus (coronal view) to the (B) left inferior lobar bronchovascular bundle, and (C) within the main right fissure.

Fig 2

Awake ECMO implantation algorithm. ECMO, extracorporeal membrane oxygenation. CT, computed tomography; EMCO,

Fig 3

Noninvasive ventilation strategies prior to ECMO implantation. ECMO, extracorporeal membrane oxygenation. ECMO, extracorporeal membrane oxygenation; HFNC, high-flow nasal cannula; PEEP, positive end expiratory pressure.