Assessing the impact of chronic lung disease on an acute respiratory event can make determining ECMO candidacy very tricky. Patients with baseline chronic lung disease which requires home O2 at rest, is generally regarded as a contraindication to ECMO support since these patients usually have very little reserve, making it hard to recover from another significant respiratory event like pneumonia, ARDS, etc.

Many centers have supported patients with a past history of COPD, who are not active smokers, and who have a reasonable baseline status which does not require home O2, at rest, or with activity. And there have been occasional cases of complete recovery to baseline in patients with fairly severe baseline disease.

Shirley presents with a different scenario. She has a 100Pack year history of tobacco use, and only recently quit for the surgery. Post-operatively she develops acute respiratory failure which does not improve. However, her CXR is not consistent with any of the usual causes of acute respiratory failure such as reaction to CPB, TRALI, aspiration pneumonia, VAP, etc. and suggests that she had very severe underlying lung disease, perhaps underestimated in her preoperative evaluation. With this in mind, after 2 weeks on 100% FiO2 and high vent pressures, it was felt that she was very unlikely to recover significant lung function, and would not be a candidate for ECMO based on the principle of reversibility. She expired the following day.