Successful Treatment of a Patient with COVID-19-Induced Severe ARDS, Pneumothorax, and Pneumomediastinum with Awake vv-ECMO Implantation

Abstract

Management of acute respiratory distress syndrome (ARDS) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is still a challenge for the staff on intensive-care units (ICU's) around the world. Many of these patients are treated with invasive ventilation. Sometimes, the occurrence of pneumothorax and/or pneumomediastinum can complicate the course of the disease because initiation of invasive ventilation might be fatal in those patients. Venovenous extracorporal membrane oxygenation (vv-ECMO) is increasingly used to prevent patients with severe ARDS from hypoxia. However, clear recommendations for or against the initiation of vv-ECMO in awake patients are currently lacking. We present the case of a 42-year-old patient with COVID-19-associated severe ARDS, pneumothorax, and pneumomediastinum. To preserve sufficient oxygenation and to avoid invasive ventilation, we implanted a vv-ECMO while the patient was awake. The patient recovered and was discharged home 41 days after transfer to our hospital. We therefore suggest that awake implantation of vv-ECMO might be useful in a subgroup of patients with severe ARDS caused by SARS-CoV-2. However, further evidence is needed to verify our hypothesis.

Figure 1

Initial chest CT-scan at the level of tracheal bifurcation directly after transfer to our ICU. The white arrows indicate bilateral ground glass opacities. Yellow arrows display the pneumomediastinum. The red arrow points at the thoracic drainage which was placed during the stay in the referring hospital.

Figure 2

Chest CT-scan 31 days after ECMO implantation, the same level as Figure 1. The pneumothorax and pneumomediastinum completely abated, and the ground glass opacities profoundly receded.