key: cord-0780996-5yfhlf2c
authors: Demarest, Caitlin T.; Tang, Paul C.
title: Commentary: “Preparedness in the Time of COVID”: Implications for Engagement of the Health Care Team with Acute Respiratory Failure
date: 2020-06-15
journal: JTCVS techniques
DOI: 10.1016/j.xjtc.2020.05.030
sha: 70d5429f9f3f1dd6217b84d8c1c1b1a7db368cef
doc_id: 780996
cord_uid: 5yfhlf2c

nan

Central Message: Through preparedness and practice, the ability to expeditiously put COVID patients on ECMO while keeping staff safe allows for the swift treatment of patients before a diagnosis is known.

Central Picture Legend: Caitlin T. Demarest, MD, PhD and Paul C. Tang, MD, PhD E-cigarette, or vaping, products have been available for over 10 years. These devices emit aerosols containing nicotine, flavoring, and often other additives including tetrahydrocannabinol.

They were initially lauded as less-harmful alternatives to inhalational tobacco products, but in 2019 there was a nation-wide outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) with more than 2500 hospitalizations and 60 deaths. 1 Patients with EVALI may present with tachycardia, tachypnea, hypoxia, leukocytosis, and chest CT findings of bilateral ground-glass opacities. 2 EVALI ranges from a mild pneumonitis to life-threatening acute respiratory distress syndrome (ARDS), with more than 30% of patients requiring intubation. 3 In cases of rapidly progressive ARDS, swift institution of extracorporeal membrane oxygenation (ECMO) can avoid lung injury associated with high pressure ventilator settings, and lead to faster recovery. This seems to be particularly true to EVALI as pulmonary infiltration resolves more expediently than in other etiologies of ARDS. 4 EVALI presentation can be difficult to distinguish from COVID-19, which could lead to diagnostic quandaries during this pandemic. Due to the nascent experience with COVID-19, there is no strong consensus on the use of ECMO for COVID-19, but the World Health Organization recommends ECMO as a rescue therapy for patients with COVID-19 and refractory hypoxemia. 5, 6 However, during this pandemic we must pay particularly astute attention to the safety of medical staff to ensure personal well-being as well as maintenance of a healthy work force. Certainly, careful allocation of resources is needed, and ECMO for COVID-19 should be offered by centers with adequate resources, and for patients with the potential for meaningful recovery.

Ramanathan et al. emphasized the need for ECMO preparedness during the COVID-19 pandemic. 7 Institutions with the resources to provide ECMO to COVID-19 patients must ensure that they have systems in place to allow complex therapeutic interventions while adhering to strict infection control measures. There should be a thoughtful, prearranged plan and well defined indications for initiating ECMO based on institutional capacity and regional COVID-19 burden. Personnel needs to be meticulously educated about the correct use of personal protective equipment and all ECMO-related procedures should be practiced in a simulation environment.

In this issue of JTCVS Techniques, Hayanga and colleagues 8 applied many of the aforementioned principles including preparedness drills utilizing high-fidelity scenarios with mock pumps and mannequins. This allowed for a reproducible response of all team members and procedures as well as identifying holes that may have been otherwise overlooked. In their case, ECMO was used to successfully treat a patient with presumptive ARDS secondary to COVID-19. While her diagnosis turned out to be EVALI, the authors' methods of rigorous preparedness allowed them to initiate and carry-out ECMO while ensuring the safety of staff. With the increase in availability of COVID-19 testing, hopefully clinicians can obtain diagnoses more expeditiously such that ECMO doesn't need to be initiated with full viral precautions in patients without a COVID-19 diagnosis. This will lessen the demands on personal protective equipment. However, with proper preparation, safe deployment of ECMO with minimal risk to staff should be achievable.

Update: Characteristics of a Nationwide Outbreak of E-cigarette, or Vaping, Product Use-Associated Lung Injury -United States

Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury -United States

Vaping-Induced Acute Lung Injury

Extracorporeal Membrane Oxygenation Support for Vaping-induced Acute Lung Injury

Preparing for the Most Critically Ill Patients With COVID-19: The Potential Role of Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO): does it have a role in the treatment of severe COVID-19?

Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases

Extracorporeal Support to Treat E-cigarette or Vaping Product Useassociated Lung Injury (EVALI) During a COVID Pandemic