Acute Crit Care.  2022 Aug;37(3):470-473. 10.4266/acc.2021.01109.

COVID-19–related acute respiratory distress syndrome treated with veno-venous extracorporeal membrane oxygenation and programmed multi-level ventilation: a case report

• Depta F
• Turčan A
• Török P
• Kapraľová P
• Gentile MA

• KMID: 2535312
• DOI: http://doi.org/10.4266/acc.2021.01109

Abstract

We report a patient with severe coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) treated with veno-venous extracorporeal membrane oxygenation (VV ECMO) and programmed multi-level ventilation (PMLV). VV ECMO as a treatment modality for severe ARDS has been described multiple times as a rescue therapy for refractory hypoxemia. It is well known that conventional ventilation can cause ventilator-induced lung injury. Protective ventilation during VV ECMO seems to be beneficial, translating to using low tidal volumes, prone positioning with general concept of open lung approach. However, mechanical ventilation is still required as ECMO per se is usually not sufficient to maintain adequate gas exchange due to hyperdynamic state of the patient and limitation of blood flow via VV ECMO. This report describes ventilation strategy using PMLV during “resting” period of the lung. In short, PMLV is a strategy for ventilating non-homogenous lungs that incorporates expiratory time constants and multiple levels of positive end-expiratory pressure. Using this approach, most affected acute lung injury/ARDS areas can be recruited, while preventing overdistension in healthy areas. To our knowledge, case report using such ventilation strategy for lung resting period has not been previously published.

Keyword

acute respiratory distress syndrome; COVID-19; programmed multi-level ventilation; veno-venous extracorporeal membrane oxygenation

Figure

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  Figure 1. Schematic representation of pressure vs. time curve scheme when PCV ventilation (A) and programmed multi-level ventilation (PMLV) is activated on top of PCV (B).PEEP: positive end-expiratory pressure; PEEPh: PEEP high; PEEPh2: PEEP high2; Ppc: pressure of pressure control.

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  Figure 2. Computed tomography (CT) scan showing classical appearance of acute phase acute respiratory distress syndrome with pneumomediastinum on Bi-Level ventilation at admission (day 1, A) and CT scan after weaning from programmed multi-level ventilation (day 14, B).

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