Bleomycin-induced lung injury treated with venovenous extracorporeal membrane oxygenation (ECMO) and ultra-protective ventilator settings

Bleomycin treats malignancies, such as germ cell tumours and Hodgkin lymphoma. While efficacious, it can cause severe drug-induced lung injury. We present a 42-year-old patient with stage IIB seminoma treated with radical orchiectomy followed by adjuvant chemotherapy with bleomycin, etoposide and cisplatin. His postbleomycin course was complicated by the rapid onset of hypoxic respiratory failure, progressing to acute respiratory distress syndrome and requiring venovenous extracorporeal membrane oxygenation (VV-ECMO) support. Although the patient was treated with high dose systemic steroids and ultra-protective ventilator strategies to minimise ventilator-induced lung injury while on VV-ECMO, his lung injury failed to improve. Care was withdrawn 29 days later. Lung autopsy revealed diffuse organising pneumonia. We found six case reports (including this one) of bleomycin-induced lung injury requiring VV-ECMO with a cumulative survival of 33% (2/6). While VV-ECMO may be used to bridge patients to recovery or lung transplant, the mortality is high.

E-cigarette, or vaping, product use-associated lung injury (EVALI) treated with veno-venous extracorporeal membrane oxygenation (VV-ECMO) and ultra-protective ventilator settings

A 19-year-old man vaping with tetrahydrocannabinol presented with dyspnoea and right pneumothorax. History, imaging and negative infectious workup were consistent with E-cigarette, or vaping, product use-associated lung injury (EVALI). Treated with systemic steroids, he developed acute respiratory distress syndrome and was intubated requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO) by hospital day 3. Using VV-ECMO, very-low tidal volume ventilation of 1.5 cc/kg was achieved, as was daily ambulation. VV-ECMO was decannulated on hospital day 9 and the patient was extubated the next day. He was discharged home on hospital day 13 without oxygen. At post-intensive care unit clinic follow-up, he had lost 20 kg of weight while hospitalised and reported nightmares. Patients with EVALI may be supported with VV-ECMO, which allows ultra-lung-protective mechanical ventilation that may minimise ventilator-induced lung injury. Follow-up in patients with EVALI is essential to diagnose and treat comorbidities, follow lung function and prevent relapses.