Impaired Blood Flow? Tension Pneumothorax on Extracorporeal Support : ASAIO Journal

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Impaired Blood Flow? Tension Pneumothorax on Extracorporeal Support

Circelli, Alessandro*; Antonini, Marta Velia*,†; Spiga, Martina*; Scognamiglio, Giovanni*; Benni, Marco*; Russo, Emanuele*

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doi: 10.1097/MAT.0000000000001743

A 55-year-old patient experiencing severe coronavirus disease 19 (COVID-19) related acute refractory respiratory failure requiring venovenous extracorporeal membrane oxygenation (VV-ECMO) support, with femoro-femoral approach, suddenly developed both signs of drainage failure and return obstruction, with extracorporeal blood flow (EBF) inconsistency, evolving to impairment, at the same time with severe desaturation, and hemodynamic instability. To support differential diagnosis, a focused point of care lung ultrasound was performed, showing no lung sliding in all explorable left fields. Chest X-ray, immediately obtained, revealed a large left-sided tension pneumothorax (Figure 1, Figure, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A814), with left lung completely collapsed, tracheal deviation, and mediastinal shift toward the right side, involving heart, superior and inferior vena cava, as suggested by displacement of intravascular devices. Particularly, drainage cannula and return cannula, are clearly visible: the latter appeared markedly misaligned with the spine, compared to previous assessments (Figure 2). After left-sided chest tube insertion, the left lung appeared mostly re-expanded (Figure 3), with mediastinal structures back to conventional anatomical site. Target EBF flow was restored, with stabilization of both hemodynamics and peripheral saturation. Small residual apical pneumothoraxes remain, with right-sided previously known, and daily assessed with lung ultrasound after chest tube insertion to manage the first episode of spontaneous pneumothorax occurred before ECMO implementation. In patients requiring extracorporeal support due to acute respiratory distress syndrome, particularly in the COVID-19 population, known to be at high risk of barotrauma,1,2 an acute decrease in the ECMO inlet pressure (increased negativity),3,4 deteriorating EBF, compromizing therapy effectiveness, and increased post-membrane lung (return) pressure may suggest acute development of clinically significant pneumothorax, or significant worsening of preexisting pneumothorax, requiring prompt intervention to restore cardiovascular physiology and decrease intrathoracic pressure, allowing for EBF to be early reestablished.5

F1
Figure 1.:
Chest x-ray obtained at time of deterioration: large tensions with left lung completely collapsed, tracheal deviation, and mediastinal shift. ECMO drainage cannula (blue arrow) and return cannula (white arrow) are clearly visible (bottom left), with return cannula significantly right-deviated and misaligned with spine; right atrium, distal end of central venous line (light blue oval), and esophageal catheter (light blue star) also appears deviated toward right hemithorax; light blue triangle: right chest tube; light blue oval: distal end of central venous line in SVC; light blue square: tracheostomy cannula. ECMO, extracorporeal membrane oxygenation; SVC, superior vena cava.
F2
Figure 2.:
Chest x-ray obtained at time of ECMO initiation: drainage and return cannula are visible (bottom left), aligned with spine;. White arrow: tip of ECMO return cannula at IVC/RA junction; blue arrow: tip of drainage cannula in IVC. A chest tube (light blue triangle:) could be noticed on the right, with a small residual right sided pneumothorax at right apex. Light blue oval: distal end of central venous line in SVC; light blue square: tracheostomy cannula; light blue star: esophageal catheter; a pulmonary artery catheter is also visible, with distal end in right pulmonary artery. ECMO, extracorporeal membrane oxygenation; IVC, inferior vena cava; RA, right atrium; SVC, superior vena cava.
F3
Figure 3.:
Chest x-ray obtained at time of pneumothorax decompression: normal cardiovascular anatomy is restored, and ECMO return cannula (blue arrow) appears re-aligned with spine; light blue triangles: chest tubes; light blue oval: distal end of central venous line in SVC; light blue square: tracheostomy cannula; light blue star: esophageal catheter. ECMO, extracorporeal membrane oxygenation; SVC, superior vena cava.

References

1. Lemmers DHL, Abu Hilal M, Bnà C, et al.: Pneumomediastinum and subcutaneous emphysema in COVID-19: barotrauma or lung frailty? ERJ Open Res. 6: 00385–02020, 2020.
2. Chong WH, Saha BK, Hu K, Chopra A: The incidence, clinical characteristics, and outcomes of pneumothorax in hospitalized COVID-19 patients: a systematic review. Heart Lung. 50: 599–608, 2021.
3. Zwischenberger JB, Cilley RE, Hirschl RB, Heiss KF, Conti VR, Bartlett RH: Life-threatening intrathoracic complications during treatment with extracorporeal membrane oxygenation. J Pediatr Surg. 23: 599–604, 1988.
4. Zwischenberger JB, Bowers RM, Pickens GJ: Tension pneumothorax during extracorporeal membrane oxygenation. Ann Thorac Surg. 47: 868–871, 1989.
5. Zakhary B, Vercaemst L, Mason P, Lorusso R, Brodie D: How I manage drainage insufficiency on extracorporeal membrane oxygenation. Crit Care. 24: 151, 2020.

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