• Gianluca Paternoster, Pietro Bertini, Alessandro Belletti, Giovanni Landoni, Serena Gallotta, Diego Palumbo, Alessandro Isirdi, and Fabio Guarracino.
• Department of Cardiac Resuscitation and Intensive Care, San Carlo Hospital, Potenza, Italy.
• J. Cardiothorac. Vasc. Anesth. 2022 Aug 1; 36 (8 Pt B): 297529822975-2982.

ObjectivesTo assess the efficacy of an awake venovenous extracorporeal membrane oxygenation (VV-ECMO) management strategy in preventing clinically relevant barotrauma in patients with coronavirus disease 2019 (COVID-19) with severe acute respiratory distress syndrome (ARDS) at high risk for pneumothorax (PNX)/pneumomediastinum (PMD), defined as the detection of the Macklin-like effect on chest computed tomography (CT) scan.DesignA case series.SettingAt the intensive care unit of a tertiary-care institution.ParticipantsSeven patients with COVID-19-associated severe ARDS and Macklin-like radiologic sign on baseline chest CT.InterventionsPrimary VV-ECMO under spontaneous breathing instead of invasive mechanical ventilation (IMV). All patients received noninvasive ventilation or oxygen through a high-flow nasal cannula before and during ECMO support. The study authors collected data on cannulation strategy, clinical management, and outcome. Failure of awake VV-ECMO strategy was defined as the need for IMV due to worsening respiratory failure or delirium/agitation. The primary outcome was the development of PNX/PMD.Measurements And Main ResultsNo patient developed PNX/PMD. The awake VV-ECMO strategy failed in 1 patient (14.3%). Severe complications were observed in 4 (57.1%) patients and were noted as the following: intracranial bleeding in 1 patient (14.3%), septic shock in 2 patients (28.6%), and secondary pulmonary infections in 3 patients (42.8%). Two patients died (28.6%), whereas 5 were successfully weaned off VV-ECMO and were discharged home.ConclusionsVV-ECMO in awake and spontaneously breathing patients with severe COVID-19 ARDS may be a feasible and safe strategy to prevent the development of PNX/PMD in patients at high risk for this complication.Copyright © 2022 Elsevier Inc. All rights reserved.

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