View Abstract

A5267 - Is It a Bridge Too Far? Ambulatory VV-ECMO as a Bridge to Lung Recovery or Transplant in a Pediatric Patient with Presumed End-Stage Lung Disease Due to Idiopathic Respiratory Failure
Author Block: L. C. Steffes1, C. K. Conrad2, Y. Yarlagadda3, M. Mafla3, K. Ryan3, K. Maeda3; 1Pediatric Pulmonary, Lucile Salter Packard Children's Hospital, Palo Alto, CA, United States, 2Stanford Univ Med Ctr, Palo Alto, CA, United States, 3Lucile Salter Packard Children's Hospital, Palo Alto, CA, United States.
Extracorporeal membrane oxygenation (ECMO) can be used in patients with severe respiratory failure. If pulmonary injury is irreversible, lung transplant (LTx) may be considered. Historically, patients requiring ECMO prior to Ltx demonstrated dismal outcomes. With advances in technology, recent studies have shown that venovenous (VV) ECMO may serve as a reasonable bridge to LTx. Improved outcomes have been shown when patients awaiting LTx on ECMO participate in physical rehabilitation. We describe the case of a healthy child who developed acute respiratory failure who is being successfully supported with ambulatory ECMO as a bridge to lung transplant. Our patient is a 9 year old healthy male with acute respiratory distress of unknown etiology, potentially related to aspiration of chlorinated pool water three days prior to presentation. Initially, he required treatment with non-invasive positive pressure, but due to rapid deterioration, he was intubated for mechanical ventilation. Initial imaging revealed a pattern of acute respiratory distress syndrome (ARDS). He worsened and developed multiple broncho-pleural fistulae, requiring chest tubes. A lung biopsy demonstrated pulmonary fibrosis with no etiology identified. He received a tracheostomy for long-term ventilation and acutely worsened, with severe impairment of ventilation and oxygenation. VV ECMO was initiated using the single lumen Avalon catheter. He had no evidence of discernable lung function and was therefore considered for lung transplant. He developed difficulties with the ECMO circuit with high clot burden and impaired flow through the circuit, thus, his ECMO was optimized with two-vein centrifugal VV ECMO. This permitted less sedation and participation in physical rehabilitation, allowing for consideration of actively listing for transplant. Since central VV ECMO placement, patient’s sedation has been weaned substantially. He is now able to stand with assistance. Over time, there have been improvements in lung compliance and oxygenation, though chest imaging continues to show diffuse pulmonary fibrosis. Historically, ECMO has been a contraindication for LTx in the pediatric population. Active wait time for LTx can be up to years for children under twelve. Recent data obtained with newer techniques do not measure survival rates that are significantly different in pediatric patients that attain ambulatory ECMO prior to transplant. Ambulatory ECMO may be an acceptable option in patients requiring respiratory support while awaiting transplant. As well, ambulatory VV-ECMO may serve as a bridge to lung recovery allowing for further treatment of severe ARDS and other etiologies of respiratory failure.