Extracorporeal Membrane Oxygenation as Adjunctive Therapy for Refractory Hypoxemic Respiratory Failure in HIV-positive Patients With Severe Pneumocystis jirovecii Pneumonia

Abstract

In the United States, Pneumocystis jirovecii (PCP) is a leading cause of morbidity and mortality in hospitalized patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and can result in severe hypoxemia despite maximal conventional ventilator support. We present 2 adult patients with HIV/ AIDS and PCP who were managed with extracorporeal membrane oxygenation (ECMO) because of refractory hypoxemia. After prolonged hospitalization, the first patient developed multiorgan failure, and the decision was made to withdraw life support. The second patient required ECMO for 7 days and survived. We also review 2 previously published cases in which ECMO was used in adult HIV patients with severe hypoxemia from PCP. In the patients that survived, ECMO was initiated earlier in the course of hospitalization compared with those that died (mean 3.5 vs. 15 d). Furthermore, the patient that survived required a much shorter duration of ECMO support (mean 5.5 vs. 41.5 d). The use of ECMO early in the course of hospitalization can be considered in patients with HIV/AIDS and refractory hypoxemia due to PCP.

The use of extracorporeal membrane oxygenation in human immunodeficiency virus–positive patients: a review of a multicenter database

“…Several case reports and small series describe the use of ECMO in patients with HIV and respiratory failure. [3][4][5][6][7][8][9][10][11][12][13][14][15] The bias toward reporting successful cases is evident in the 93% survival of the 14 patients reported in these studies. In another study, Capatos et al 16 describe an aggressive approach to the management and cannulation of HIV patients with severe respiratory failure within three institutions in South Africa, with the authors reporting a survival to discharge among their 22 patients of 68% in all patients and 60% in those with Pneumocystis jirovecii pneumonia (PJP).…”

Severe acute respiratory distress syndrome in a patient with AIDS successfully treated with veno‐venous extracorporeal membrane oxygenation: a case report and literature review

“…In terms of timing of ECMO initiation, it seems ideal to start ECMO within 7 days from ventilator introduction based on the ELSO guideline 12 and Respiratory ECMO Survival Prediction (RESP) score. 14 In addition, as Goodman et al 4 reported, patients given ECMO early during their ventilator management course showed higher survival rates (Table 3).…”

“…There are several reports of successful ECMO use for severe hypoxia in patients with HIV/AIDS. [2][3][4][5][6][7][8][9][10] However, key therapeutic issues, such as mechanical ventilation (MV) settings, indications for ECMO, and the timing of antiretroviral therapy (ART), have not always been discussed in these reports. A case of acute respiratory distress syndrome in a patient with novel HIV/ AIDS, who was successfully treated with veno-venous (V-V) ECMO and discharged, is presented.…”

ECMO Support in HIV/AIDS with Pneumocystis Jirovecii Pneumonia: A Case Report and Short Review

“…As for the timing of ECLS initiation in PJP, Goodman [10] reported that apart from higher survival rates, the early usage of ECMO during the course of MV can result in a shorter duration of ECMO support in patients. Similarly, Obata [20] also reported that early ECMO introduction can produce early achievement of lung rest management.…”