Commentary: "Preparedness in the time of COVID": Implications for engagement of the health care team with acute respiratory failure.

Caitlin T. Demarest, MD, PhD, and Paul C. Tang, MD, PhD

Through preparedness and practice, the ability to expeditiously put COVID patients on extracorporeal membrane oxygenation while keeping staff safe allows for the swift treatment of patients before a diagnosis is known.

See Article page 381.

E-cigarette, or vaping, products have been available for more than 10 years. These devices emit aerosols containing nicotine, flavoring, and often other additives, including tetrahydrocannabinol. They were initially lauded as less-harmful alternatives to inhalational tobacco products, but in 2019 there was a nationwide outbreak of e-cigarette or vaping product use–associated lung injury (EVALI), with more than 2500 hospitalizations and 60 deaths. Patients with EVALI may present with tachycardia, tachypnea, hypoxia, leukocytosis, and chest computed tomography findings of bilateral ground-glass opacities.

EVALI ranges from a mild pneumonitis to life-threatening acute respiratory distress syndrome (ARDS), with >30% of patients requiring intubation. In cases of rapidly progressive ARDS, swift institution of extracorporeal membrane oxygenation (ECMO) can avoid lung injury associated with high-pressure ventilator settings, and lead to faster recovery. This seems to be particularly true for EVALI, with pulmonary infiltration resolving more expediently than in other etiologies of ARDS.

EVALI presentation can be difficult to distinguish from COVID-19, which could lead to diagnostic quandaries during this pandemic. Owing to the nascent experience with COVID-19, there is no strong consensus on the use of ECMO for patients with COVID-19, but the World Health Organization recommends ECMO as a rescue therapy for patients with COVID-19 and refractory hypoxemia., However, during this pandemic, we must pay particularly astute attention to the safety of medical staff, to ensure personal well-being as well as maintenance of a healthy work force. Certainly, careful allocation of resources is needed, and ECMO for COVID-19 should be offered by centers with adequate resources and for patients with the potential for meaningful recovery.

Ramanathan and colleagues have emphasized the need for ECMO preparedness during the COVID-19 pandemic. Institutions with the resources to provide ECMO for patients with COVID-19 must ensure that systems are in place to allow complex therapeutic interventions while adhering to strict infection control measures. There should be a thoughtful, prearranged plan and well-defined indications for initiating ECMO based on institutional capacity and regional COVID-19 burden. Personnel need to be meticulously educated about the correct use of personal protective equipment, and all ECMO-related procedures should be practiced in a simulation environment.

In their article in this issue of JTCVS Techniques, Hayanga and colleagues apply many of the aforementioned principles, including preparedness drills using high-fidelity scenarios with mock pumps and mannequins. This allowed for a reproducible response of all team members and procedures and also identified holes that otherwise might have been overlooked. In their case, ECMO was used to successfully treat a patient with presumptive ARDS secondary to COVID-19. Although the patient's diagnosis turned out to be EVALI, the authors' rigorous preparations allowed them to provide ECMO while ensuring the safety of staff. With the increasing availability of COVID-19 testing, hopefully clinicians can obtain diagnoses more expeditiously such that ECMO does not need to be initiated with full viral precautions in patients without a COVID-19 diagnosis. This will reduce the demands on personal protective equipment. However, with proper preparation, safe deployment of ECMO with minimal risk to staff should be achievable.