A 12-year-old previously healthy boy presented with fever and cough for 5 – 6 days and breathlessness for a day. At the referral hospital, NIV was initiated followed by invasive ventilation. However, he could not maintain saturations (30-40%) despite high settings on conventional ventilation.
On arrival, he was electively placed on High-Frequency Oscillatory Ventilation (HFOV). Despite high ventilatory settings, his saturations continued to be low. Broad-spectrum empiric antibiotic therapy for community-acquired pneumonia (CAP-typical and atypical) was initiated.
The history, examination findings, chest radiograph and arterial blood gas (ABG) findings showed severe Acute Respiratory Distress Syndrome (ARDS) and a massive left-sided pleural effusion, which was promptly drained with an intercostal drainage (ICD) tube. The child had refractory hypoxemia and respiratory acidosis. The ECMO team was alerted and Veno-venous Extra-Corporeal Membrane Oxygenation (VV-ECMO) was initiated; after which the oxygenation and carbon dioxide levels improved.
On day 3, Broncho-Alveolar Lavage (BAL) fluid confirmed M. pneumoniae. Antibiotic coverage was narrowed and continued for 14 days. The child also developed intra-vascular hemolysis on day 6 due to cold-agglutinins. Warming of the patient, and of blood products ameliorated the hemolysis.
ECMO support was gradually weaned off by the 14th day as respiratory parameters kept improving. Conventional Mechanical Ventilation (CMV) followed by Non-Invasive Ventilation (NIV) and High Flow Nasal Cannula (HFNC) were used to wean respiratory support.
Apart from transient critical illness myopathy, the child made an uneventful recovery without any nosocomial infections. Supportive measures were addressed: measures to prevent pressure ulcers, and deep venous thromboses, physiotherapy and good quality nursing care. Reassurance about improving condition and moral support was given to the child and parents continually, along with necessary financial support.
- Every patient is a teacher and Every Life matters!
- Unusual occurrence of severe ARDS with an atypical bacteria like Mycoplasma should be aggressively managed.
- Early recognition, prompt transfer to a tertiary or quaternary centre and escalation of respiratory management can change outcomes radically in severe ARDS
- The initiation of ECMO at the right time is prudent in refractory hypoxemia and is a path changer in outcomes along with multispecialty teamwork.
- Supportive, specialized care and good infection control protocols, which tends to be usually ignored, can also help transform results.
It was heartening to see the patient walk in into the OPD for follow-up without residual deficits after a life-threatening illness.
Acknowledgments: Pediatric ECMO team (Surgeons, Perfusionists, Intensivists), Rehab team, PICU Nursing team and Dr. Tanu Singhal.