Awake Venovenous Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019 Acute Respiratory Failure

Abstract

Supplemental Digital Content is available in the text.

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

“…Mortality and intubation rate in this study are comparable to a previous case series on awake VV-ECMO in COVID-19 and non-COVID ARDS patients 32,37 and are lower as compared with case series on immunocompromised patients. 35 Comparison with data from other series is generally difficult, as in several cases awake ECMO was not the first strategy, and patients underwent IMV first, 21,36 but the authors' results here are nevertheless encouraging.…”

“…The use of ECMO in awake, spontaneously breathing patients has been described previously in several case series in patients with ARDS, 32 cardiogenic shock, 33 waiting for lung transplantation, 34 immunocompromised, 35 and in mixed respiratory failure populations, 36 including cases of ECMO before intubation. 19,35,37 In addition, the successful application of the VV-ECMO approach instead of IMV has already been described in patients with COVID-19. 19,20,37,38 Schmidt et al reported a successful case of awake VV-ECMO in a patient with severe ARDS who refused intubation.…”

“…19,35,37 In addition, the successful application of the VV-ECMO approach instead of IMV has already been described in patients with COVID-19. 19,20,37,38 Schmidt et al reported a successful case of awake VV-ECMO in a patient with severe ARDS who refused intubation. 19 Similarly, Azzam et al reported the case of a patient with extensive surgical emphysema, PMD, and bilateral PNX, in which ECMO was used instead of mechanical ventilation.…”

“…In a small case series of 7 patients by Assanangkornchai et al, 4 patients ultimately required intubation, and 1 died. 37 Compared to all these studies, in the authors' case series, the decision to start awake VV-ECMO instead of IMV was undertaken after the evaluation of chest CT scans that classified patients at high risk for subsequent barotrauma development. The authors' previous experience in patients with COVID-19 with ARDS showed that Macklin-like radiological sign has an 89% sensitivity and a 95% specificity in predicting PNX/PMD development; ie, 33 out of 39 Macklin-positive patients (84%) developed overt PNX/PMD within the next 12 days.…”

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

“…Evidence of application of vv-ECMO in awake patients is currently shaky [9]. A retrospective case series describing eight cases where awake vv-ECMO was applied in COVID-19 patients with severe ARDS found a mortality rate of only 14.3% (1 patient) [12]. Other single case reports also showed promising results [13][14][15].…”