PMC8279878_01
Axial chest computed tomography scan. (a) Before the first extracorporeal membrane oxygenation support. Diffuse bilateral ground glass opacity pattern and right pleural effusion are shown. (b) During the first extracorporeal membrane oxygenation support. Thickening of interstitial septa and diffuse crazy paving are shown. (c) After the first decannulation of extracorporeal membrane oxygenation. Lung aeration improved bilaterally with partial resolution of ground glass opacities.
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Chest computed tomography (CT) scan showed diffuse bilateral ground glass opacity pattern and right pleural effusion with no sign of pulmonary embolism (Figure 1(a)). Crs further deteriorated (8 mL/cmH2O), and a second chest CT scan revealed thickening of interstitial septa and diffuse crazy paving pattern, suggestive of pulmonary fibrosis (Figure 1(b)). After two cycles of prone positioning with poor response and 22 days of lung rest, Crs gradually improved, ventilation of the native lung was carefully increased, and extracorporeal support was finally successfully discontinued (Figure 1(c)).
Electrical impedance tomography decremental positive end-expiratory pressure (PEEP) trial during the first extracorporeal membrane oxygenation support. In (a), the regional distribution of tidal ventilation at different PEEP values is shown by the blue-white gradient area, while the yellow area represents regional ventilation delay (RVD), whose percentage is indicated by the yellow number. In (b), regional compliance (C) is analyzed at different PEEP values. Compliance loss secondary to high PEEP (HP) is represented by the orange area (i.e., lung overdistension), while compliance loss due to low PEEP (LP) is represented by the white area (i.e., lung collapse). The percentage amounts of compliance loss associated with HP and LP are quantified by the orange and white numbers, respectively. In (c), RVD and compliance loss due to HP and LP at the different values of PEEP are plotted in order to facilitate the selection of the patient's best PEEP. This electrical impedance analysis shows the extreme heterogeneity of ventilation distribution, reflecting the severe and diffuse lung parenchyma abnormalities, documented also by chest computed tomography.
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Lung ultraprotective ventilation was established with VT 2 mL/kg IBW and EIT-guided PEEP titration (Figure 2).
Chest X-ray. (a) A week after the first extracorporeal membrane oxygenation weaning. Bilateral pneumonia is shown. (b) After the second decannulation of extracorporeal membrane oxygenation. Partial resolution of bilateral pneumonia with persistence of diffuse loss of aeration is shown.
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New-onset ARDS was diagnosed (Figure 3(a)), as characterized by PaO2/FiO2 of 90 mmHg, PaCO2 of 65 mmHg, and pH 7.26. Pseudomonas aeruginosa, while real-time polymerase chain reaction for SARS-CoV-2 on nasopharyngeal swab tested negative. Patient's clinical conditions and chest X-ray slowly improved, and ECMO was discontinued 12 days later (Figure 3(b)).