Extracorporeal membrane oxygenation for tuberculosis pneumonia with empyema

Epidemiology and outcomes of patients with tuberculosis requiring extracorporeal membrane oxygenation: An ELSO registry analysis

PURPOSE

This study aimed to analyze data from the Extracorporeal Life Support Organization (ELSO) registry to elucidate the epidemiology and outcomes of patients with tuberculosis necessitating extracorporeal membrane oxygenation (ECMO), an intervention typically employed in treating severe acute respiratory distress syndrome (ARDS), but infrequently reported in tuberculosis contexts.

METHODS

A retrospective analysis was conducted utilizing the ELSO registry data spanning from 2003 to 2022, specifically targeting patients with tuberculosis who underwent ECMO. Primary outcomes included survival to hospital discharge, while secondary outcomes encompassed pre-ECMO support, ECMO duration, complications, and discharge destinations. Univariate and multivariate Cox proportional hazard regression analyses were employed to identify factors influencing survival rates.

RESULTS

The analysis included 169 patients with tuberculosis, with a median ECMO support duration of 233 h. The weaning success rate was recorded at 62.7 %, and 55 % of patients achieved survival to hospital discharge. Complications arose in 69.8 % of cases, predominantly mechanical complications (46.6 %). Multivariate Cox regression analysis identified complications (HR: 0.448, 95 % CI: 0.222-0.748, P=0.001), infections (HR: 0.483, 95 % CI: 0.241-0.808, P=0.001), and prolonged intervals from admission to ECMO initiation (HR: 0.698, 95 % CI: 0.396-0.901, P=0.018) as significant factors correlated with decreased survival likelihood.

CONCLUSION

ECMO presents as a viable treatment option for patients with tuberculosis; however, timely initiation and meticulous management are critical to mitigate complications and enhance patient outcomes.

IMPLICATION FOR CLINICAL PRACTICE

Accurate identification of optimal ECMO initiation timing for eligible patients with tuberculosis can significantly enhance clinical outcomes in critical care settings, such as intensive care units.

ECMO support may be associated with improved survival in tuberculosis associated severe ARDS

BACKGROUND

Data describing outcome of extracorporeal membrane oxygenation (ECMO) support in Tuberculosis (Tbc)-associated acute respiratory distress syndrome (ARDS) remain sparce and are mostly confined to singular case reports. The aim of this case series was to analyze intensive care unit (ICU) survival in patients with Tbc-associated ARDS receiving veno-venous (vv-) ECMO support and to compare those to patients not receiving ECMO.

CASE PRESENTATION

ICU survival was analyzed retrospectively in 14 patients treated for Tbc-associated ARDS at three ECMO-referral university hospitals (Hannover Medical School, University Hospital Bonn (both Germany) and University Hospital Zurich (Switzerland)) during the last 14 years, of which eight patients received additional vv-ECMO support and six standard care only. ICU survival was significantly higher in patients receiving additional vv-ECMO support (62.5%, n = 5/8) compared to those that did not (16.7%, n = 1/6) (p = 0.021). ECMO support was associated with reduced ICU mortality (Hazard ratio adjusted for baseline SOFA score [adj. HR] 0.125 (95% confidence interval (CI): 0.023-0.689), p = 0.017). Median (IQR) time on ECMO and invasive ventilation in the vv-ECMO group were 20 (11-26) and 37 (27-53) days, respectively. Major bleeding defined as transfusion requirement of 4 units of blood or more or surgical and/or radiologic intervention occurred only in one patient, in whom pulmonary bleeding was fatal. Thromboembolic events occurred in none of the vv-ECMO patients.

DISCUSSION AND CONCLUSIONS

This retrospective analysis from three large ECMO centers with similar SOPs suggests vv-ECMO support as a feasible approach in patients with severe Tbc-associated ARDS. Although affiliated with extended runtimes, vv-ECMO might be associated with improved survival in those patients. Vv-ECMO support should thus be considered in Tbc-associated ARDS to enable lung protective strategies during prolonged lung recovery.

Diagnosis and ECMO Treatment of a Critically Ill Patient With Disseminated Mycobacterium tuberculosis: A Case Report

Background

Mycobacterium tuberculosis infection remains a public health concern worldwide. The diagnosis and treatment of disseminated M. tuberculosis is very difficult, so we shared our experiences and lessons learned in this case report.

Case Presentation

A 36-year-old female with a history of epilepsy presented to our hospital with fever, upper abdominal pain, muscle soreness in limbs for 7 days, and shortness of breath for 4 days. On admission, she presented with acute respiratory distress syndrome (ARDS) and liver dysfunction. Due to the critical nature of her clinical presentation, the patient was admitted directly to the Intensive Care Unit (ICU), received mechanical ventilation in prone position and VV-ECMO treatment. Her condition improved gradually, and the ECMO was removed after 7 days and she was weaned off the ventilator after 8 days. However, her fever recurred and she underwent PET-CT examination, liver contrast ultrasound, acid-fast staining and second-generation sequencing of cerebrospinal fluid, which confirmed M. tuberculosis infection.

Conclusion

This case report briefly described the treatment and diagnosis of a critically ill patient with intra and extra-pulmonary tuberculosis infection. Timely and appropriate treatment is crucial to save lives, but the timing of ECMO treatment needs to be carefully considered for patients with ARDS caused by tuberculosis.