Alicia Lew, MD
University of South Florida Morsani College of Medicine
Tampa, Florida
Disclosure information not submitted.
Tisha Spence, MD
Assistant Professor of Pediatric Critical Care Medicine
Johns Hopkins All Children's Hospital, United States
Disclosure information not submitted.
Ashley Siems, MD, MEd
MD, MEd
Johns Hopkins All Children's Hospital, United States
Disclosure information not submitted.
Anthony Sochet, MD, MS
Assistant Professor, Anesthesiology and Critical Care Medicine
Johns Hopkins All Childrens Hospital
St Petersburg, Florida
Disclosure information not submitted.
David Kays, MD
Medical Director of The Center for Congenital Diaphragmatic Hernia
Johns Hopkins All Children's Hospital, United States
Disclosure information not submitted.
Beatriz Teppa, MD
Assistant Professor of Pediatric Critical Care Medicine
Johns Hopkins All Children's Hospital, United States
Disclosure information not submitted.
Title: Extracorporeal Life Support for Air-Leak Syndrome from COVID-19 Pneumonia in Two Adolescent Cases
Introduction: In the United States, 1.7% of COVID-19 cases occur in children. Of the 0.5-2% requiring intensive care unit admission, only 23 cases of extracorporeal life support (ECLS) are reported. We describe two adolescents with COVID-19 acquired air-leak syndrome who received ECLS.
Description: Case 1: A 13-year-old obese female with asthma presented with < 1 day of altered mentation and acute respiratory distress syndrome requiring endotracheal intubation. COVID-19 polymerase chain reaction (PCR) testing was positive. She received remdesivir, dexamethasone, tocilizumab, and enoxaparin. Despite open lung ventilation, she developed severe subcutaneous emphysema on day 4 and was cannulated for venovenous (vv) ECLS. With lung rest, her emphysema resolved. She was decannulated on day 9, extubated on day 13, underwent elective tracheostomy on day 49, and was discharged on day 61.
Case 2: A 19-year-old male with pre-B cell acute lymphoblastic leukemia status post hematopoietic stem cell transplantation presented with fever and dyspnea. Imaging revealed multifocal pneumonia and he was positive for COVID-19 by PCR. He received remdesivir, dexamethasone, enoxaparin, and non-invasive ventilation (NIV). On day 11, progressive hypoxemia, subcutaneous emphysema, and pneumothoraces prompted intubation and cannulation for vv-ECLS (Figure 1). Despite lung rest strategies and thoracostomy decompression, his pneumothoraces were refractory and he developed Aspergillus pneumonia. After 45 days he was compassionately withdrawn.
Discussion: Our cases highlight the potential of ECLS for refractory air-leak from COVID-19, a complication not yet described in children and typically associated with aggressive conventional ventilation. We speculate barometric and inflammatory injury to lung parenchyma from COVID-19 increases the risk of air leak syndrome. In our cases, this occurred during NIV and open lung ventilation. We recommend limiting excessive driving pressures with strategies such as extubation for spontaneous ventilation, open lung ventilation, unilateral ventilation, high-frequency oscillation, or airway pressure release ventilation. If ECLS is required, extended circuit life may be achieved with reduced thrombotic/hemorrhagic events with bivalirudin anticoagulation to permit sufficient time to resolve air-leak.