title: Extra corporeal membrane oxygenation to facilitate lung protective ventilation and prevent ventilator-induced lung injury in severe Pneumocystis pneumonia with pneumomediastinum: a case report and short literature review.
abstract: BACKGROUND
  Pulmonary infections caused by Pneumocystis jirovecii in immunocompromised host can be associated with cysts, pneumatoceles and air leaks that can progress to pneumomediastinum and pneumothoraxes. In such cases, it can be challenging to maintain adequate gas exchange by conventional mechanical ventilation and at the same time prevent further ventilator-induced lung injury. We report a young HIV positive male with poorly compliant lungs and pneumomediastinum secondary to severe Pneumocystis infection, rescued with veno-venous extra corporeal membrane oxygenation (V-V ECMO).
  
  
  METHODS
  A 26 year old male with no significant past medical history was admitted with fever, cough and shortness of breath. He initially required non-invasive ventilation for respiratory failure. However, his respiratory function progressively deteriorated due to increasing pulmonary infiltrates and development of pneumomediastinum, eventually requiring endotracheal intubation and invasive ventilation. Despite attempts at optimizing gas exchange by ventilatory maneuvers, patients' pulmonary parameters worsened necessitating rescue ECMO therapy. The introduction of V-V ECMO facilitated the use of ultra-protective lung ventilation and prevented progression of pneumomediastinum, maintaining optimal gas exchange. It allowed time for the antibiotics to show effect and pulmonary parenchyma to heal. Further diagnostic workup revealed Pneumocystis jirovecii as the causative organism for pneumonia and serology confirmed Human Immunodeficiency Virus infection. Patient was successfully treated with appropriate antimicrobials and de-cannulated after six days of ECMO support.
  
  
  CONCLUSIONS
  ECMO was an effective salvage therapy in HIV positive patient with an otherwise fatal respiratory failure due to Pneumocystis pneumonia and air leak syndrome.
authors.affiliation: Department of Medical ICU, Hamad General Hospital, P.O. Box 3050, Doha, State of Qatar, Qatar. drhusainali@gmail.com.
authors.forename: Husain Shabbir
authors.initials: HS
authors.lastname: Ali
authors.affiliation: Department of Medical ICU, Hamad General Hospital, P.O. Box 3050, Doha, State of Qatar, Qatar.
authors.forename: Ibrahim Fawzy
authors.initials: IF
authors.lastname: Hassan
authors.affiliation: Department of Medical ICU, Hamad General Hospital, P.O. Box 3050, Doha, State of Qatar, Qatar.
authors.forename: Saibu
authors.initials: S
authors.lastname: George
mesh_terms: D000328:Adult; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging / Q000503:physiopathology*; D008170:Lung Compliance; D008297:Male; D008478:Mediastinal Emphysema / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D011020:Pneumonia, Pneumocystis / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D012121:Respiration, Artificial / Q000009:adverse effects*; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D055397:Ventilator-Induced Lung Injury / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*
keywords: Extra corporeal membrane oxygenation; Human immunodeficiency virus; Pneumocystis jirovecii pneumonia; Pneumomediastinum