A25-19 Independent Lung Ventilation While on VV ECMO

Abstract Introduction Independent Lung Ventilation (ILV) can be considered for asymmetric lung disease and is often applied using a dual-lumen airway. We present a case where ILV used a unique airway-configuration to allow for resolution of bronchopleural fistulas (BPF) while on VV ECMO. Case Description 41 year-old woman with Flu-A and secondary VAP was transferred for ECMO evaluation on day 9 of MV with prolonged paralysis. Pneumothoracies occurred due to aggressive bag ventilations after sudden loss of airway prior to ECMO initiation, with ongoing large left-sided air-leaks due to presumed BPF. After ∼7 days on ECMO, native oxygenation recovered substantially but her native ventilation remained poor. To heal her BPF, MV support was drastically reduced while her ECMO support (sweep) and sedation were intensified but within 24 hours overt recirculation developed due to RV failure. We instituted ILV since her right lung required moderate support for recruitment while allowing healing of the left-sided BPF. She had severe MDR PSA pneumonia complicated by bacteremia and left pleural-space infection so a bronchial blocker to isolate the left lung was not ideal nor was a double-lumen ETT since its small-diameter lumen can impede secretion clearance. Instead, we advanced an 8-0 ETT via her trach site into her right-main bronchus utilizing bronchoscopy to avoid occluding her RUL and applied APRV-TCAV to recruit and stabilize her right lung; We placed HFNC at 30L/min, 40% FiO2 for low-intensity support with humidification of the left lung while she breathed spontaneously. Recirculation resolved immediately as her PVR decreased when right lung volume was restored while allowing her left lung to have ambient pressure was sufficient to allow improved RV function but still reduce air-leaks. After twelve days, left-sided air-leaks resolved and her right lung had been stabilized and was now on lower MV settings, so her airway was pulled back into the distal trachea for standard ventilation. Her left-sided chest tubes were removed sequentially, and she was decannulated on ECMO day 60. Discussion ILV can be applied in settings of asymmetric lung disease so that specific support can be tailored to each hemithorax. When lung rest is applied on VV ECMO, acute RV failure may occur due to elevated PVR from loss of lung volume below FRC inducing overt recirculation. ILV may be helpful to avoid the need to convert ECMO strategy (VA or VPa) by applying specific MV support to each lung and safely rescue the failing RV. This abstract is funded by: None