Marium Khan, MD
Resident
University of Virginia
Charlottesville, VA
Disclosure information not submitted.
Melissa Yildirim, BS, MD
Pediatric Critical Care Fellow
University of Virginia School of Medicine
Charlottesville, VA
Disclosure information not submitted.
.jpg "Michael Spaeder, MD, MS, FCCM photo")
Michael Spaeder, MD, MS, FCCM
Associate Professor/Fellow Director
University of Virginia School of Medicine
Charlottesville, VA
Disclosure information not submitted.
Title: Management of Fulminant Pediatric Respiratory Failure and Persistent Air Leak due to COVID-19 ARDS
Case Report Body:
Introduction: COVID-19 pneumonia in children is a generally mild illness. A small proportion have progressed to have severe respiratory disease requiring prolonged mechanical ventilation, and their management has relied heavily on adult literature secondary to the paucity of data on the management of COVID-19 associated pediatric acute respiratory distress syndrome (pARDS). Here we describe a case of a persistent air leak in a pediatric patient with severe COVID-19 pARDS and discuss its management.
Description: A previously healthy 4-year-old girl was admitted to our pediatric intensive care unit (PICU) following a pedestrian vs motor vehicle accident. Prior to arrival, she was intubated and a chest tube was placed for a pneumothorax. The patient was recovering well when she acutely developed refractory hypoxemia. Chest radiograph revealed a recurrent pneumothorax necessitating a second chest tube. Subsequent bronchoscopy demonstrated severe mucous plugging. Her respiratory failure progressed to require urgent venovenous extracorporeal membrane oxygenation (VV-ECMO). While she had tested negative for COVID-19 on admission, she was re-tested with this decompensation and found to be PCR positive. Her course was complicated by a persistent air leak, confirmed to be a broncho-pleural fistula (BPF) via imaging. The management of her COVID-19 ARDS and associated BPF involved prolonged VV-ECMO support with jet ventilation and supportive care.
Discussion: BPF most commonly occur post-operatively but can also occur after a pneumothorax in the setting of underlying lung disease. The recommended management is a short observation period followed by surgical management with pleurodesis or lobectomy. For patients who are not surgical candidates, bronchoscopic interventions may also be considered. Our patient was not a candidate for surgical nor bronchoscopic interventions secondary to her tenuous state and the distal location of her BPF. To help heal her BPF, we thus chose to mechanically ventilate her via jet ventilation to help reduce mean and driving airway pressures with the goal of minimizing flow through the BPF. A chest tube was also left in place for continuous evaluation of her air leak. Over 15 weeks, the patient was slowly weaned from ECMO and the ventilator and was discharged home with no respiratory support.