When encountering a 45yo patient with life-threatening acute respiratory failure and insufficient understanding of the etiology disease process, we would generally support the patient with an assumption that it is likely a treatable process, and we should continue the search. Amelia was placed on VV ECMO with a RIJ double-lumen cannula and her ventilator settings reduced, and her paralytics and sedation stopped. On ECMO Day #2 she had a tracheostomy placed, an open lung biopsy obtained, and a flexible bronchoscopy performed which showed some grayish mucosa with patchy inflammation, but without any purulence. BAL vultures were obtained, later reported as negative. The lung biopsies (RLL and RML) demonstrated non-specific organizing pneumonia, with alveolar wall thickening,and hyaline membranes consistent with diffuse alveolar damage. Immunohistologic stains for adenovirus, CMV, and HSV were all negative. The consensus was to continue the steroids with a presumed diagnosis of collagen vascular disease, but additional AVD therapy was not warranted without a diagnosis. She woke up appropriately, and was tolerating full enteral feeds. One week later a repeat bronchoscopy showed improvement in the inflammation, and the CXR was also beginning to clear, and her saturations were in the high 90’s; evidence that her lungs were now contributing to some gas exchange. From there she remained stable, but progress was very slow. Then on ECMO Day #14, she had a sudden drop in her WBC, began requiring fluid for hypotension, and her urine output fell. Her blood cultures returned positive for MRSA, enterococcus, and Candida tropicalis. Over the ensuing days she rapidly developed profound multisystem failure including liver failure, and expired.

It is pretty easy to defend providing Amelia a chance with VV ECMO. As the ECMO physicians and specialists, our role with VV ECMO is to takeover lung function and provide gas exchange to sufficiently contribute to DO2, while resting the lungs. But ECMO is a support system, not a treatment, and it does not address the etiology. The patient’s recovery depends on the entire team identifying and treating the underlying cause of the respiratory failure, and unfortunately, that is not always possible.