Early Initiation of Venovenous Extracorporeal Membrane Oxygenation for Critically Ill COVID-19 Patients

The optimal timing for initiating extracorporeal membrane oxygenation (ECMO) after starting mechanical ventilation has yet to be clarified. We report herein the cases of two patients with coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) who were successfully managed with an early ECMO induction strategy. Case 1 involved a 64-year-old man admitted in respiratory distress with polymerase chain reaction-confirmed COVID-19. On day 5 at hospital, he was intubated, but oxygenation remained unimproved despite mechanical ventilation treatment with high positive end-expiratory pressure (PEEP) (PaO₂/FiO₂ [P/F] ratio, 127; Respiratory ECMO Survival Prediction [RESP] score, 4). ECMO was initiated 4 hours after intubation, and stopped on day 16 at hospital. The patient was discharged from hospital on day 36. Case 2 involved a 49-year-old man who had been admitted 8 days prior. He was intubated on hospital on day 2. High PEEP mechanical ventilation did not improve oxygenation (P/F ratio, 93; RESP score, 7). ECMO was stopped on hospital on day 7 and he was discharged from hospital on day 21. The strategy of early initiation of ECMO in these two cases may have minimized the risk of ventilation-related lung injury and contributed to the achievement of favorable outcomes.