When should lung transplant be considered for severe COVID-19 associated ARDS?

Abstract

Background: COVID-19 can cause severe respiratory failure and acute respiratory distress syndrome (ARDS). Lung transplantation is a potentially lifesaving treatment for patients with COVID-19–associated ARDS, but uncertainty still surrounds patient selection and timing of referral.

Study objective: To identify factors associated with recovery (weaning from ECMO and intensive care unit discharge) versus death of patients with covid-19-associated ARDS on Extracorporeal Membrane Oxygenation (ECMO) listed for lung transplantation.

Methods: Retrospective review of all consecutive cases referred to our center and listed for lung transplantation between January and December 2021. Factors associated with recovery versus death while on the waitlist were assessed.

Results: Sixteen patients were included in the study: 2 underwent a lung transplant, 8 recovered, and 6 died. The median time on the transplant wait list was 20 days. Patients who recovered were significantly younger (47 vs. 58) with a trajectory towards decreased time on ECMO (71.5 vs. 83.5) and a longer time interval between hospital admission and initiation of mechanical ventilation (7 vs. 2.5 days), ECMO (9 vs. 4 days) or listing for transplant (75 vs. 56.5 days).

Conclusions: Although the question regarding which of the patients on ECMO due to COVID-19 ARDS needs lung transplant remains unanswered, it appears that younger patients are more likely to recover without transplant even after a prolonged period on ECMO.