Introduction: Cavitary tuberculosis (TB) can lead to life-threatening respiratory failure, necessitating extracorporeal membrane oxygenation (ECMO) therapy. Data is limited regarding therapeutic approaches for pediatric patients with severe cavitations. We present a successful outcome with the use of prolonged complete lung rest and veno-venous (VV) ECMO. Description: A healthy 9-month-old male presented with acute hypoxemic and hypercapnic respiratory failure secondary to disseminated TB with areas of cavitation and necrosis of the right lung. He was intubated, required high frequency oscillatory ventilation, anti-tubercular therapy, and ultimately VV-ECMO due to progressive respiratory failure. His initial ECMO run was for 8 days, after which his oxygenation and ventilation improved, and imaging demonstrated improved consolidations and cavitations. Despite extubation and negative pressure ventilation, he developed progressively worsening right lung cavitary lesions, hypoxemia, and hypercapnia, and required a second prolonged VV-ECMO run, lasting 54 days, with complete lung rest and rehabilitation. Complete lung rest was accomplished with collapse therapy and the use of continuous positive airway pressure while on ECMO to promote healing and facilitate cavitary closure. Challenges during this period included development of a small extra-axial cerebral hemorrhage, pulmonary hemorrhage, opioid dependence, delirium, nutritional compromise, and need for multiple bronchoscopies for airway clearance. After 6 weeks of complete lung rest, his lungs were re-recruited and demonstrated improved compliance without recurrence of his cavitary lesions. Remarkably, the patient demonstrated gradual pulmonary recovery and was ultimately weaned off ECMO and mechanical ventilation. He was eventually discharged home on room air with continued TB antimicrobial therapy after more than three months in the hospital. Discussion: Management of respiratory failure in refractory cavitary TB can include low-pressure ventilator strategies, negative pressure ventilation, surgical resection, single-lung ventilation, endobronchial valve placement, and ECMO support. We demonstrate a successful use of prolonged complete lung rest with VV-ECMO in a 9- month-old child with severe cavitary TB.
Shah et al. (Sun,) studied this question.