Coronavirus 2019 in a Morbidly Obese Patient: ECMO or No ECMO?

INTRODUCTION: Coronavirus 2019 (COVID-19) can lead to Acute Respiratory Distress Syndrome (ARDS), necessitating prolonged mechanical ventilation and the use of extracorporeal membrane oxygenation (ECMO). A Body Mass Index (BMI) higher than 30 kg/m(2) is associated with an increased risk of developing ARDS along with greater morbidity, length of stay, and duration of mechanical ventilation in the intensive care unit. There is limited data on utilizing ECMO support in the morbidly obese population. CASE REPORT: A 51-year-old female with a history of chronic obstructive pulmonary disease and extreme obesity with BMI of 54 kg/m(2) presented with a complaint of worsening shortness of breath. She was afebrile with a temperature of 97F, tachypneic with a rate of 32, and hypoxic with oxygen saturation in the 80′s. Chest x-ray showed severe bilateral interstitial airspace opacities (figure 1). Transthoracic echocardiogram showed an ejection fraction of 55-60%. She tested positive for COVID-19 and was promptly started on dexamethasone and remdesivir. Her respiratory status continued to decline and she was intubated on day 6. Despite being on 100% Fio2, her hypoxemia persisted. We proceeded to cannulate veno-venous ECMO via the right internal jugular vein and right femoral vein. Over the next several days, her ARDS status continued to improve drastically along with oxygenation. On Day 13, she was successfully de-cannulated with no complications. The patient recovered well and was discharged to an acute rehabilitation facility. SUMMARY: ECMO has several advantages including direct pulmonary artery flow improving oxygenation and ventilation, early mobility once off the ventilator, and survival benefit. The use of veno-arterial ECMO should also be considered in the setting of severe respiratory failure accompanied by severe heart failure or right ventricular dysfunction. This case highlights the importance of considering ECMO as a feasible therapeutic option in the morbidly obese patient population with COVID-19 as it can be life-saving.