tetano
Editor, Senior Moderator
J Cardiothorac Vasc Anesth
. 2022 Mar 17;S1053-0770(22)00188-4.
doi: 10.1053/j.jvca.2022.03.011. Online ahead of print.
Venovenous Extracorporeal Membrane Oxygenation in Awake Non-Intubated Patients With COVID-19 ARDS at High Risk for Barotrauma
Gianluca Paternoster[SUP] 1 [/SUP], Pietro Bertini[SUP] 2 [/SUP], Alessandro Belletti[SUP] 3 [/SUP], Giovanni Landoni[SUP] 4 [/SUP], Serena Gallotta[SUP] 5 [/SUP], Diego Palumbo[SUP] 6 [/SUP], Alessandro Isirdi[SUP] 7 [/SUP], Fabio Guarracino[SUP] 8 [/SUP]
Affiliations
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.
. 2022 Mar 17;S1053-0770(22)00188-4.
doi: 10.1053/j.jvca.2022.03.011. Online ahead of print.
Venovenous Extracorporeal Membrane Oxygenation in Awake Non-Intubated Patients With COVID-19 ARDS at High Risk for Barotrauma
Gianluca Paternoster[SUP] 1 [/SUP], Pietro Bertini[SUP] 2 [/SUP], Alessandro Belletti[SUP] 3 [/SUP], Giovanni Landoni[SUP] 4 [/SUP], Serena Gallotta[SUP] 5 [/SUP], Diego Palumbo[SUP] 6 [/SUP], Alessandro Isirdi[SUP] 7 [/SUP], Fabio Guarracino[SUP] 8 [/SUP]
Affiliations
- PMID: 35537972
- DOI: 10.1053/j.jvca.2022.03.011
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.