The best outcome for a patient being considered for a lung transplant is deciding if a lung transplant is no longer necessary. That was the case for a young woman who was transferred to Emory University Hospital with acute respiratory distress syndrome. David Neujahr, MD, medical director of the Emory Lung Transplant Program, credits the medical team’s multidisciplinary care coordination and the Emory Extracorporeal Membrane Oxygenation Program’s expertise.
The patient, a healthy young pediatric nurse from central Georgia, fractured her collarbone in a fall in July 2020. After a local pain site injection, she developed severe staphylococcus acute respiratory distress syndrome and was transferred to Emory University Hospital for further care.
Upon admission to the intensive care unit (ICU), the patient was on 100% FiO2 with a PEEP of 15cm H2O and receiving inhaled nitric oxide to optimize ventilation-perfusion matching.
Initial treatment included prone positioning and the use of neuromuscular blocking agents to facilitate gas exchange in the lungs. However, the patient’s status continued to decline, and she developed multiple pneumothoraces due to barotrauma in a poorly compliant lung.
Advanced Cannulation Strategies
Within three days of admission to the ICU, Emory’s lung transplant team was consulted. Based on his evaluation, Dr. Neujahr and the Lung Transplant team agreed that the damage to the patient’s lungs was significant and likely irreversible.
The team recommended venovenous extracorporeal membrane oxygenation (ECMO) using a double-lumen, bi-caval Avalonä cannula. Bi-caval ECMO is one of several advanced cannulation strategies offered at Emory that allows the patient to ambulate and tolerate physical and occupational therapy. This can lead to improved conditioning, which may strengthen lung transplant candidacy or minimize the risk of frailty and other complications for those who will not need a transplant.
Cardiothoracic surgeon Mani A. Daneshmand, MD, director of the Emory Heart & Lung Transplantation, Mechanical Circulatory Support and ECMO programs, inserted the cannula using transesophageal echocardiography (TEE) guidance. The catheter (which has an inner and outer lumen) allows simultaneous venous drainage and reinfusion of blood.
Multidisciplinary Team Approach
Within two weeks of going on venovenous ECMO, the patient was able to walk around the ICU with nurses and engage in therapy at the bedside. Members of the lung transplant team supervised the patient’s progress and adjusted her ECMO support.
Although the likelihood of a transplant still remained, the Lung Transplant team began to notice that with careful medical management, the patient could recover without a transplant.
Deciding Against Lung Transplant
Within six weeks of admission, the patient had shown significant progress as evidenced by:
- CT scans that showed improved aeration and healing in the lungs
- Improvement in arterial blood gases during sweep gas off trials
- Improved lung compliance
Dr. Neujahr and his team agreed that the patient would not need a lung transplant and three weeks later the patient was decannulated from ECMO.
Four days later, on October 20, 2020, she was discharged to Emory Rehabilitation Hospital on 2L/minute supplemental oxygen. She spent about two weeks at the facility receiving physical, occupational and speech therapy and was discharged home without the need for supplemental oxygen.
Recovery and Follow-Up
One of the more unusual aspects of this case was the contrast between the two possible outcomes. For several weeks, the care team was simultaneously preparing to list the patient for lung transplant while also thinking she may fully recover without a transplant. The patient’s youth and physical status prior to her lung injury played a role in the healing process, which was also aided by the medical team’s experience and expertise in advanced cannulation and intensive care protocols, including an emphasis on mobility.
For more information about the Emory Lung Transplant Program or to refer a patient, call 1-855-EMORY-TX (366-7989) or visit emoryhealthcare.org/txrefer.
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