COVID-19: Extracorporeal carbon dioxide removal as rescue therapy in severe Covid-19 pneumonitis

  Srilagna Sarkar, Amity University Kolkata

Coronavirus disease 2019, was first identified in Wuhan where 27 patients cases reported of pneumonia of some unknown aetiology were linked with an open seafood market. Despite several measures, the virus spread rapidly and by 11 March 2020 WHO declared it as a global pandemic.

In the majority of patients suffering from Covid-19, mild illness, sometimes asymptomatic behaviour and severe respiratory failure from acute respiratory distress syndrome (ARDS) has been noticed.

In a recent case of a 48- year old man with a history of asthma and hypercholesterolaemia was admitted with 7 days of cough, fever and shortness of breath. A chest X-ray was conducted demonstrating bilateral infiltrates and a respiratory viral swab was tested positive for Covid-19. He was then reportedly treated with Extracorporeal carbon dioxide removal therapy.

During the initial stages of his treatment, he managed with oxygen facemask and oral doxycycline to treat the existent bacterial pneumonia but evolving respiratory failure was noticed and hence was trialled on continuous positive airway pressure (CPAP) but no improvement as seen despite all of it. On the fourth day, he was shifted to the Intensive care unit and his trachea was intubated to provide mechanical ventilation.

On subsequent week his condition still kept worsening and therefore, he was taken to a local ECMO centre for refractory ARDS but the referral was declined. Then the treating team decided to consider extracorporeal carbon dioxide as rescue therapy. They initiated this using the Hemolung RAS device which allowed to reduce high airway pressure to facilitate lung-protective ventilation. Any further ventilation with elevated pressure levels would have been deleterious and would have propagated inflammatory process contributing to ARDS.

After 6 days of the Hemolung without bleeding or vasopressor requirement, the patient could continue with prone position ventilation without any complication and he improved to a certain point where spontaneous ventilation was restored and the Hemolung was weaned off and after 37 days of intensive care he was discharged for the home with 4 days with mobility and cognition intact.

It, therefore, seems reasonable for clinicians to consider the use of extracorporeal carbon dioxide removal as rescue therapy in severe ARDS in preference of ECMO if ECMO is not deemed appropriate or isn’t available for resource constraints.

Source: Association of Anaesthetists. https://doi.org/10.1016/j.ijid.2020.03.058

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