- A 37-year-old male was admitted with cough, fever and worsening shortness of breath. He required non-invasive ventilation but did not improve and was intubated. - He was started on ECMO due to worsening hypoxemia not responding to prone positioning. Cultures grew multiple organisms and antibiotics were escalated. - Over 10 days, the patient gradually improved on ECMO. He was successfully weaned off ECMO support and decannulated. After further improvement, he was discharged on room air.

1. CASE PRESENTATION
PRESENTER- Dr MANI PRASAD REDDY
MODERATOR- Dr SWARNA DEEPAK

2. CHIEF COMPLAINTS
• 37 year old male software employee by occupation was admitted
from ER to MICU with chief complaints of
• cough since 8days
• Fever since 5days
• Breathlessness since 3days

3. HISTORY OF PRESENTING ILLNESS
• Cough since 8days,insidious in onset, gradually progressive, not
associated with expectoration, chest pain, no diurnal,postural and
seasonal variation.
• Fever since 5days insidious in onset, gradually progressive,
continuous, low grade, subsided with medication, not associated with
chills and rigors, sweating, headache, rash.
• Shortness of breath since 3days insidious in onset MMRC grade 1
gradually progressed to grade IV, associated with wheeze.
• No history of orthopnea, PND, syncope, chest pain, palpitations.

4. Past history- No comorbidities / History of previous hospital admission
1yr back for covid pneumonia recovered and required minimal oxygen
support.
Family history- No similar complaints in family / no other relevant
history
Personal history- Consumes mixed diet , reduced appetite , disturbed
sleep due to SOB, bowel and bladder – regular and normal; Smoker – 5-
10 cigarettes/day for 10 years  10 pack years, occasional alcohol
intake.

5. • Patient initially took treatment on OPD basis for 3days with above
complaints.
• In view of worsening SOB he came to our hospital for further
management.

6. At ER
• Patient was tachypneic, tachycardic and restless at presentation
• HR- 132bpm
• BP- 126/78 mmHg
• Rr- 36/min
• SPO2- 78% on RA
• SPO2- 86% with NRBM mask with 15 litres O2 support.

7. ABG on 15 LIT O2 NRBM
• Patient was started on NIV support
• All routine investigations ( CBP, RFT, LFT, Sr ELECTROLYTES,
CXR, PT/INR) were sent from ER
• HRCT chest was done.
• Blood culture and sensitivity sent, patient wa started on
empirical antibiotics.
PH
PCO2
PO2
HCO3
LACTATES
P/F

8. HRCT CHEST

9. AT MICU
• Patient was shifted to MICU on NIV support
• FiO2 – 1; PS-12cm H2O; PEEP- 6cm H2O

10. General physical examination
• A middle aged male conscious oriented to place person
• Class –I Obesity with BMI 34.5kg/m
• (weight -112kgs Height -180cms)
• No pallor/icterus/clubbing/lymphadenopathy/cyanosis/pedal edema.

11. • Pulse-132bpm checked in radial artery; regular; good volume; normal
character; no radio radial and radio femoral delay; all peripheral
pulses felt.
• BP- 140/85 mm hg measured in right arm supine position
• RR- 36 breaths /min, thoracoabdominal type with use of accessory
muscles of respiration
• Temperature- 101.4F( left axilla)
• SpO2- 88% on NIV

12. SYSTEMIC EXAMINATION
• RESPIRATORY SYSTEM
• Shape of chestwall- symmetrical
• Trachea – appears to be central
• Use of accessory muscles of respiration +
Apical impulse – not visualised due to obesity
• Auscultation- harsh vesicular breath sounds all over the lung fields;
B/L inspiratory crepitations Right > Left , polyphonic rhonchi+

13. • CVS: S1 S2 heard, no murmers
• P/A: Soft, non tender, liver and spleen not palpable, bowel sounds+
• CNS: conscious, oriented GCS – 15/15
B/L pupils mmractive to light; Tone : normal ; Power5/5
B/L plantor flexors.
Provisional diagnosis
Lower respiratory tract infection
B/L pneumonia
Impending respiratory failure

14. INITIAL LAB VALUES
HB 16.5 g/dl
TLC 3250 cells/ cumm
PC 1.7 lacs/ cumm
S.Creatinine 0.6mg/dl
Serum Na/K 141/4.3 mmol/l
LFT WNL
PT/INR 13.1 sec/ 0.96
D-dimer 2216.14
Procalcitonin 0.6 ng/ml

15. POCUS
• USG CHEST – Bilateral B profile with lung slide+
dynamic air bronchogram+ right upper lobe; no pleural
effusion
• 2DECHO- IVC 1.5cm, < 50% collapsibility; good LV function, No RWMA
• Patient continued to have tachypnea, tachycardia and using accessory
muscles of respiration.

16. • ABG was repeated after 1 hour on NIV
• Patient was in impending respiratory failure with no response to NIV
trial.
• Patient was intubated, sedation and muscle relaxants continued
• Mechanical ventilator settings
• MODE - VCV
FiO2 TV PEEP RR I:E
100 400 14 32 1:2
P/F 86
PH 7.31
PCO2 60
PO2 70
HCO3 26

17. VITALS POST INTUBATION
• HR – 124bpm; BP- 122/82 mmhg; SpO2 91% with FiO2- 100%
• ABG after 2hrs
• ET cultures, H1N1, Covid RT- PCR sent
• Invasive lines ( CVP; ARTERIAL LINE ) were secured
• Planned for prone ventilation
PH 7.37
PCO2 59
PCO2 68.6
HCO3 31
P/F 81

18. Proning session-1
• Firs session of proning done for 16hours.
• Patient was sedated and paralysed
• All pressure points secured
• No hemodynamic instability
• RT feeds started at 40ml/hour
• ABG after 8hours of proning with FiO2 90%
P/F 105
PH 7.36
PCO2 48.6
PO2 95.3

19. Day2-4
• Total 3 sessions of proning done
• Mechanical ventilation continued
MODE FiO2 TV PEEP RR I:E
PRVC 80 400ml 16 35 1:2
ABG DAY 1 DAY 2 DAY 3
P/F 105 125 109
PH 7.36 7.37 7.32
PCO2 48.6 52.9 56.9
PO2 95.1 74.8 87.5
HCO3 27 28.2 28

20. LAB VALUES
DAY 2 DAY 3 DAY 4
HB 15.1 14.7 13.7
TLC 3570 2950 5320
PC 1.8 1.9 2.5
S. Creatinine 0.6 0.7 0.6
Serum Na/K 142/3.8 142/4.3 146/4.6

21. • CXR- increase in B/L infiltrates
• V-V ECMO was planned as patient did not respond to 3 sessions of prone
ventilation
• Patient attenders were counselled regarding all the pros and cons of ECMO
and consent was taken.
• CTVS referral was given
• V-V ECMO initiated,(Right Femoral and Right IJV cannulated) with FIO2-
100% Sweep gas 6.6L/min; Blood flow 4.5L/min
• Heparin infusion was started, with target ACT of 180
• ACT repeated 2nd hourly and ABG 6th hourly
• RT feeds were continued at the rate of 75ml/hour

22. ECMO PIC

23. Before ECMO After ECMO
P/F 109 225
PH 7.32 7.52
PCO2 56.9 36
PO2 87.5 91
HCO3 28 29.4

24. • ET C/s was positive for Pseudomonas Aeruginosa
• Antibiotics were escalated
• Inj. Imipenem + cilastin was added
• Inj. Cefperazone + sulbactam was stopped
• BAL was done and samples were sent for culture sensitivity and
pneumonia film array panel

25. DAY 5-10
• H1N1 influenza A positive
• BAL samples positive for Acinetobacter baumanii,
• Pneumonia panel positive for Acinetobacter baumanii, pseudomonas
aeruginosa, Escherichia coli.
• Antibiotics were escalated according to the sensitivity
• TLC was 11,200 cells/ cumm

26. • ACT checked 4th hourly and titrated the heparin ( target ACT 180 –
220)
• ABG was done every 8th hourly
• APTT was monitored 12th hourly
• ECMO sweep gas flows were gradually titrated and reduced from (
6.5l/min on day 1 ECMO to 4.5l/min)
• Patiennt P/F ratios were around 150
• Lung transplant team referral was given

27. • CT Chest was done in view of refractory hypoxemia and difficulty to
wean off ECMO
• Bronchoscopy and bronchial toileting was done
• Thick mucopurulent secretions were seen in B/L lower lobes.
• BAL sample collected and mucolytic agent was instilled into
tracheobronchial tree.

28. • Percutaneous tracheostomy done in view of prolonged ventilator
support on day 9 of admission
P/F 185
PH 7.33
PCO2 42.9
PO2 73.9
HCO3 22.4
ABG
MODE FiO2 TV PEEP RR I:E
PRVC 40 400 16 30 1:2
MECHANICAL VENTILATOR SETTINGS
FiO2 RPM BLOOD FLOW SGF
100% 3210 4.5 L/ min 4.5 L/min
ECMO SETTINGS

29. DAY 6 DAY 8 DAY 10
HB 11 10.8 10.1
TLC 5860 4480 10490
PC 2.8 2.6 3.1
S. Creatinine 0.7 0.7 0.8
Serum Na/K 149/3.8 151/3.5 150/3.8

30. • Patient showed improvemt in lung meachanics and chest Xray
• He was conscious and obeying commands
• ECMO was weaned and SGF reduced to 4.5L/ min 2.5 L/ min 0
on day 15
• Patient was monitored overnight with SGF -0

31. DAY 16
• ABG before decannulation with SGF 0 L/ min
P/F 166
PH 7.45
PCO2 49.4
PO2 100
FiO2 TV PEEP RR 1:E
60 400 12 32 1:2

32. DAY 16
• SGF were 0 L/min for 17 hours
• P/F ratio- 166
• Patient was conscious, obeying and comfortable
• Patient was decannulated

33. DAY 16 - 25
• Patient was conscious,comfortable
• CXR was improving
• MV support was weaned to FIO2 40%
• Antibiotics were de-escalated; steroids stopped
• Chest and limb physiotherapy continued
• Mobilized to chair
• Patient was weaned to AVAPS support thermovent O2 support room air
• Patient was shifted to O2 room on Day 18 with TT
• Tracheostomy tube was decannulated on D-20
• Patient was discharged thereafter.

34. CHEST XRAYS

35. • THANK YOU