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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 155-157

Complete pulmonary recovery after COVID-19 infection requiring extracorporeal membrane oxygenation: A case report


1 Department of Cardiothoracic Surgery, The Medical Center of Aurora, Aurora, CO, USA
2 Department of Cardiac Perfusion, Specialty Care Perfusion Services, Nashville, TN, USA

Date of Submission27-Jul-2020
Date of Acceptance26-Aug-2020
Date of Web Publication22-Sep-2020

Correspondence Address:
Dr. Michael S Firstenberg
Department of Cardiothoracic Surgery, The Medical Center of Aurora, 1444 S. Potomac Street, Suite 200, Aurora, CO 80012
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCIIS.IJCIIS_132_20

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   Abstract 


Severe pulmonary complications associated with COVID-19 infections are a substantial source of morbidity and/or mortality. Extracorporeal membrane oxygenation (ECMO) has been shown to be a potentially useful therapy in the management of severe COVID-19 infection as a means to facilitate pulmonary recovery. Despite growing evidence to demonstrate the utility of ECMO for COVID-19 respiratory failure, little is known regarding the posthospital discharge recovery and functional status of these patients. Furthermore, concerns regarding potential long-term complications, but data are lacking. We illustrate a case of a previously healthy male, who was supported on ECMO for severe COVID-19 who demonstrated what appears to be a complete subjective and objective pulmonary recovery within a short time postdischarge. Our case provides some optimisms that critically-ill COVID-19 patients might recover completely and be able to return to functional lives.

Keywords: Acute respiratory distress syndrome, COVID-19, extracorporeal membrane oxygenation, pulmonary function, recovery


How to cite this article:
Firstenberg MS, Libby M, Roberts R, Petersen C, Hanna J. Complete pulmonary recovery after COVID-19 infection requiring extracorporeal membrane oxygenation: A case report. Int J Crit Illn Inj Sci 2020;10:155-7

How to cite this URL:
Firstenberg MS, Libby M, Roberts R, Petersen C, Hanna J. Complete pulmonary recovery after COVID-19 infection requiring extracorporeal membrane oxygenation: A case report. Int J Crit Illn Inj Sci [serial online] 2020 [cited 2020 Dec 4];10:155-7. Available from: https://www.ijciis.org/text.asp?2020/10/3/155/295775




   Introduction Top


The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been devastating globally, with millions of reported cases and significant associated mortality. In addition, there are growing concerns regarding the short- and long-term morbidities associated with coronavirus disease 2019 (COVID-19) even in patients who survive, especially for those who present with severe respiratory complications requiring admission to an intensive care unit and mechanical ventilation. Reports of up to an 80% mortality have been reported in patients requiring mechanical ventilation and, as such, have prompted consideration for other rescue therapies such as extracorporeal membrane oxygenation (ECMO).[1],[2] Even with ECMO, registry data still report a 45% mortality, and most importantly, there are little data regarding the outcomes of patients treated with ECMO once they are discharged from the hospital.[3],[4] The concern, based on preliminary experiences with non-ECMO COVID-19 survivors, is that COVID-19 results in substantial and potentially irreversible lung injury that might have life-long consequences.[5] However, we present a case of a patient successfully supported with ECMO for COVID-19 who, on early follow-up, has had normalization of his presumed normal, pre-COVID-19, pulmonary function.


   case Report Top


Our patient is an otherwise previously healthy, active, nonsmoking, 40-year-old male who presented to an outside hospital on April 2, 2020, with a 7-day history of fevers (Tmax: 102.7°F, 39.3C) and worsening shortness of breath. On presentation, he was saturating 80% on room air, which improved to 96% with 6 l of the nasal cannula. His other vitals at presentation included: heart rate of 87 beats/min, respiratory rate of 18 breaths/min, the temperature of 39.1C, and blood pressure of 135/60 mmHg. His height was 188 cm, weight 87.7 kg, and body mass index was 25. His C-reactive protein (CRP) was 19.8 mg/dL (normal: 0.3–1.0 mg/dL). Other admission laboratories included a point of care troponin (normal, 0.0 ng/ml), creatinine of 1.17 mg/dL, carbon dioxide of 27 mmol/L, procalcitonin of 0.31 ng/ml, lactic acid of 1.5 mmol/L, normal liver transaminases, normal prothrombin time, white blood cell count (8.9 10^9/L) and differential, hemoglobin of 13.5 g/dL. No D-Dimer or brain natriuretic peptide testing was performed and per the initial assessment, since there were no complaints of leg swelling, a computed tomography (CT) scan of the chest was not performed, however, a chest X-ray demonstrated “multi-focal consolidation most consistent with typical viral bronchopneumonia” [Figure 1]a. No other source of bacterial infection or cause of acute respiratory failure was identified, and a COVID polymerase chain reaction test was positive. He required mechanical ventilation (initial setting: rate: 24/min; positive end-expiratory pressure: 14 mmHg; peak inspiratory pressure: 31 mmHg; tidal volume: 460 ml; FIO2: 0.70) the following day with a CRP of 23.6 mg/dL and a ferritin of 1039 ng/mL (normal: 38–380 ng/mL). His COVID-19 therapies are listed in [Table 1]. D-Dimer testing on April 9th was elevated to 5.25 mg/L.
Figure 1: (a) Chest X-ray obtained at the time of initial hospitalization. (b) Chest X-ray obtained at the time of initiation of extra-corporeal membrane oxygenation. (c) Chest X-ray obtained 2 days before discharge home

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Table 1: Time course of key events and therapies

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However, due to the worsening of his respiratory failure, including poor response to prone positioning and inhaled nitric oxide (40 parts/million), he was transferred to our institution for ECMO on April 7, 2020 [Figure 1]b. On arrival, he was immediately assessed by our ECMO Team (respiratory ECMO survival prediction score: 3, Class II risk, 76% predicted survival)[6] and placed on percutaneous veno-veno ECMO at the bedside (21 Fr single-stage inflow, 25 Fr multi-stage drainage cannulas with Maquet CardioHelp circuit (Maquet Cardiovascular, Wayne NJ USA). ECMO was initiated 96 h postinitiation of mechanical ventilation. At the time of cannulation, his arterial PaO2 to FiO2 (P/F) ratio was 45. He was treated with tocilizumab on April 11, and the following day, an additional unit of convalescent plasma was given. Neither he did receive remdesivir, nor did he receive steroids. Systemic heparin for the ECMO circuit was used with a target partial thromboplastin time of 40–60 s. A lung-protective strategy was employed using an airway pressure release ventilation mode that was frequently adjusted to minimize airway pressures and atelectasis.

He was successfully decannulated on April 15, 2020 (189 h on ECMO) and was extubated to the nasal cannula by April 17 with a P/F ratio of 213.

He was discharged home with his family on April 21, 2020, on room air [Figure 1]c. His COVID-19 test (Cepheid Xpress SARS-CoV-2 assay) on the day before discharge was still positive, and he was advised to self-isolate. His only medication at discharge was apixaban 5 mg po BID for a peroneal deep-vein thrombosis discovered post-ECMO.

Formal pulmonary function testing was obtained on May 6, 2020 [Table 2] and reported no abnormalities. The final interpretation was: “no evidence of obstruction, restriction, or diffusion impairment.” Outpatient COVID-19 testing was negative. The patient reported no respiratory symptoms, was walking and eventually running at least 6 miles a day and was encouraged to pursue more intensive exercise as tolerated (of note, the patient was an avid marathon runner before his illness). As he has been doing well, not further chest imaging has been performed. Although no family member tested positive for the disease, his wife tested positive for antibodies, suggesting she had been infected previously. However, she never required hospitalization or treatment and never manifested significant clinical signs or symptoms.
Table 2: Pulmonary function testing results

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   Discussion Top


Objective assessments of clinical recovery after COVID-19 remain unclear. While there is a growing body of literature regarding the heterogeneous immunologic, radiographic, and laboratory findings in patients who survive COVID-19, little has been described regarding the objective symptomatic changes.[7] In one study of 143 hospitalized patients (21/143, 15% required noninvasive ventilation, whereas 7/143, 5% required mechanical ventilation) in Italy who were assessed within 60 days after the onset of symptoms, a substantial number still reported persistent symptoms of fatigue (53%), shortness of breath (43%), joint pain (27%), and chest pain (22%) with 87% reporting at least one symptom.[8] The postdischarge recovery of patients requiring mechanical ventilation, let alone, ECMO is undefined. However, there are concerns that as many as 40% of COVID-19 patients develop respiratory complications, of which 20% are severe, and the potential development of a postrespiratory failure clinically significant and potentially debilitating fibroproliferative state is concerning given the global disease burden.[5],[9]

The long-term effects of COVID-19 remain unclear regardless of the severity of disease. Hopefully, our experience with a critically ill COVID-19 patient who required multiple salvage, compassionate use, and at the time of treatment, unproven and controversial therapies including ECMO, demonstrates the possibility of obtaining a meaningful recovery following the critical sequelae of COVID-19 infection. The fact that he was not only successfully decannulated from ECMO, extubated, and discharged home is in and of itself a reason for optimism when faced with similar critically-ill COVID-19 patients. While we were not aware of his pulmonary function before his illness, the normalization of his pulmonary function tests within a relatively short time postdischarge should provide objective hope and enthusiasm in the face of a catastrophic pandemic.


   Conclusions Top


While the global acute implications of COVID-19 on the health-care system are catastrophic, our demonstration of objective pulmonary recovery in a COVID-19 patient treated with multi-modality therapies, including ECMO is encouraging. However, this illustrates the need for further intense study of the long-term clinical outcomes following infection.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent documentation, and the patient has given permission for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Applicable reporting guideline for case reports (CARE) was followed by the authors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR network. The authors also attest that this clinical investigation was determined not to require Institutional Review Board / Ethics Committee review.



 
   References Top

1.
Weiss P, Murdoch DR. Clinical course and mortality risk of severe COVID-19. Lancet 2020;395:1014-5.  Back to cited text no. 1
    
2.
Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;323:2052-2059. doi:10.1001/jama.2020.6775.  Back to cited text no. 2
    
3.
Jacobs JP, Stammers AH, St Louis J, Hayanga JA, Firstenberg MS, Mongero LB, et al. Extracorporeal membrane oxygenation in the treatment of severe pulmonary and cardiac compromise in COVID-19: Experience with 32 patients. ASAIO J 2020;66:722-30.  Back to cited text no. 3
    
4.
Available from: https://www.elso.org/Registry/FullCOVID19 RegistryDashboard.aspx. [Last accessed on 2020 Jul 11].  Back to cited text no. 4
    
5.
Spagnolo P, Balestro E, Aliberti S, Cocconcelli E, Biondini D, Casa GD, et al. Pulmonary fibrosis secondary to COVID-19: A call to arms? Lancet Respir Med 2020;8:750-2.  Back to cited text no. 5
    
6.
Schmidt M, Bailey M, Sheldrake J, Hodgson C, Aubron C, Rycus PT, et al. Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The respiratory extracorporeal membrane oxygenation survival prediction (RESP) score. Am J Respir Crit Care Med 2014;189:1374-82.  Back to cited text no. 6
    
7.
Lan L, Xu D, Ye G, Xia C, Wang S, Li Y,et al. Positive RT-PCR test results in patients recovered from COVID-19. JAMA. 2020; 323:1502-1503. doi: 10.1001/jama.2020.2783.  Back to cited text no. 7
    
8.
Carfì A, Bernabei R, Landi F, Gemelli against COVID-19 Post-Acute Care Study Group. Persistent symptoms in patients after acute COVID-19. JAMA 2020;324:603-5.  Back to cited text no. 8
    
9.
Wu C, Chen X, Cai Y, Zhou X, Xu S, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med. 2020;180:934-943. doi: 10.1001/jamainternmed.2020.0994.  Back to cited text no. 9
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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