key: cord-0750756-91a8zro6
authors: Maeda, Akiko; Nabeya, Daijiro; Nagano, Hiroaki; Yagi, Nobuhito; Miyagi, Tadayoshi; Kishaba, Tomoo
title: Prone position ventilation and femoro‐femoral veno‐venous extracorporeal membrane oxygenation for COVID‐19 treatment
date: 2020-12-15
journal: Respirol Case Rep
DOI: 10.1002/rcr2.700
sha: 915cee76595dd7860d809124d82887516e775bb8
doc_id: 750756
cord_uid: 91a8zro6

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), which causes coronavirus disease 2019 (COVID‐19), has resulted in significant morbidity and mortality worldwide. Approximately 5% of COVID‐19 patients who suffer from pneumonia develop critical respiratory failure. Here, we report the case of a healthy 52‐year‐old man who had respiratory failure owing to SARS‐CoV‐2 infection and was treated using femoro‐femoral veno‐venous extracorporeal membrane oxygenation (VV‐ECMO) and prone position ventilation (PPV). After this treatment, his blood oxygen levels, chest high‐resolution computed tomography findings, and clinical parameters significantly improved. He was decannulated from VV‐ECMO on day 6 and finally extubated on day 11. To our knowledge, this is the first reported case of SARS‐CoV‐2‐associated acute respiratory distress syndrome that was successfully treated with a combination of femoro‐femoral VV‐ECMO and PPV.

In 2019, novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the cause of a cluster of pneumonia cases in Wuhan, China. Since then, it has spread rapidly, resulting in a pandemic. This virus causes the coronavirus disease 2019 (COVID-19), which results in considerable morbidity and mortality, largely because of the progression of acute viral pneumonia to acute respiratory distress syndrome (ARDS). In this report, we present the case of a patient who developed severe ARDS and presented with significant high-resolution computed tomography (HRCT) findings on his chest. However, after providing femorofemoral veno-venous extracorporeal membrane oxygenation (VV-ECMO) and prone position ventilation (PPV), his blood oxygen levels and lung condition significantly improved.

A 52-year-old man visited a local hospital experiencing fever as a first symptom for two days. Two days later, he was diagnosed with COVID-19. Upon providing a nasopharyngeal swab for detection by reverse transcriptionpolymerase chain reaction, he was confirmed positive for SARS-CoV-2 infection and hence admitted to a nearby general hospital. However, his respiratory status worsened, and he rapidly developed progressive hypoxaemia, requiring intubation. After intubation, he was admitted to the intensive care unit (ICU) in our hospital. Chest HRCT revealed extensive bilateral reticulation and ground-glass opacities. His initial vital signs were as follows: 36.5 C body temperature, 161/110 mmHg blood pressure, and 90% oxygen saturation with a 60% fraction of inspired oxygen (FiO 2 ). The initial arterial blood gas analysis with an FiO 2 of 80% indicated a pH of 7.318, partial pressure of carbon dioxide (PaCO 2 ) of 51.9 mmHg, partial pressure of oxygen (PaO 2 ) of 61.9 mmHg, haemoglobin oxygen saturation (SaO 2 ) of 90.3%, and lactate and bicarbonate levels of 0.9 and 23.8 mmol/L, respectively, revealing profound hypoxaemia. The mechanical ventilator settings were as follows: peak inspiratory pressure of 28 cmH 2 O, respiratory rate of 14 breaths/min, positive end-expiratory pressure (PEEP) of 14 cmH 2 O, and FiO 2 of 80%. However, respiratory failure was too severe to be controlled by an optimal mechanical ventilation strategy and medication, such as favipiravir and dexamethasone. In addition, as no other organ failure was detected, VV-ECMO was applied 3 h after admission to our hospital. Femoro-femoral VV-ECMO was performed using a 21-Fr catheter placed in the right femoral vein for inflow and a 24-Fr cannula inserted in the left femoral vein for outflow (Fig. 1A, B) , with an initial blood flow of 4.1 L/min and sweep gas flow of 4.1 L/min. The mechanical ventilator was set on a pressure-controlled mode with an inspiratory pressure of 15 cmH 2 O, respiratory rate of 10 breaths/min, PEEP of 8 cmH 2 O, and FiO 2 of 40%.

To achieve haemodynamic stability, PPV was implemented for more than 17 h from day 2 of admission to our hospital. PaO 2 gradually improved from 61.9 to 76.4 mmHg and lung compliance improved from 30 to 50 mL/cmH 2 O within 72 h of performing two cycles of ventilation. Each cycle included prone position for 17 h and supine position for 7 h (Fig. 1C) . VV-ECMO was successfully weaned off on day 6. A chest computed tomography (CT) scan was performed before extubating the patient to preclude worsening bilateral consolidation as shown in previous reports. The repeat chest CT scan revealed a new bilateral ventral reticulation, marked improvement in dorsal ground-glass opacities, and left lower lobe consolidations ( Fig. 2A) . After blood oxygen levels and clinical symptoms of the patient improved, he was successfully extubated on day 11. After timely rehabilitation, he was discharged from the hospital on day 21 (Fig. 2B ).

Here, we reported the case of a critical patient with COVID-19 pneumonia who exhibited a significantly positive response to VV-ECMO and PPV. Among the patients hospitalized with COVID-19, approximately one-quarter of them require ICU admission, and profound hypoxaemic respiratory failure from ARDS is the dominant finding in critically ill patients.

The mortality rate of patients with COVID-19 who develop ARDS ranges from 52% to 67% [1] . After the publication of the PROSEVA study [2] , PPV and lungprotective ventilation, such as low tidal volume ventilation and high PEEP, have become standard procedures for managing patients with severe ARDS. For the most severe COVID-19 pneumonia cases, the use of VV-ECMO often provides clinical benefits [3] . However, the efficacy of the femoro-femoral VV-ECMO combined with PPV remains unknown.

This case highlighted three clinically useful findings. First, PPV combined with VV-ECMO improved oxygen levels in a patient with SARS-CoV-2-associated ARDS and allowed for maintenance of his condition in an ICU. Second, venous cannulae are usually placed in the right or left femoral vein for drainage and the right internal jugular vein for infusion during VV-ECMO. However, in this case, the cannula was placed in the right femoral vein for infusion and the left femoral vein for drainage. Although femoral cannulation has traditionally been contraindicated for mobilization, we successfully performed femoro-femoral VV-ECMO without any complications. Third, the practice of using femoro-femoral VV-ECMO added the most important advantage that PPV could be performed without moving the ECMO circuit, unlike that in jugular-femoral VV-ECMO. Finally, PPV was efficient in improving the patient's blood oxygen levels and chest HRCT findings.

In conclusion, the combined femoro-femoral VV-ECMO and PPV therapy provided clinical benefits to the patient with COVID-19 and critical pneumonia, without any additional complication. 

Appropriate written informed consent was obtained for publication of this case report and accompanying images.

Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China

Prone positioning in severe acute respiratory distress syndrome

Preparing for the most critically ill patients with COVID-19: the potential role of extracorporeal membrane oxygenation

We thank all medical specialists, nurses, and allied health and intensive care specialists who were involved in patient care, helping him in many ways towards recovery.