Tube Thoracostomy Complications in Patients with ARDS Requiring ECMO: Worse in COVID-19 Patients?

Introduction: The incidence and management outcomes of COVID-19 patients with acute respiratory distress syndrome (ARDS) on veno-venous extracorporeal membrane oxygenation (V-V ECMO) requiring chest tubes are not well-described. This study sought to explore differences in tube thoracostomy rates and subsequent complications between patients with and without COVID-19 ARDS on V-V ECMO. Materials and Methods: This study is a single institution, retrospective cohort study of patients with COVID-19 ARDS requiring V-V ECMO. The control cohort consisted of patients who required V-V ECMO for ARDS-related diagnoses from January 2018 to January 2021. The primary outcome was any complication following initial tube thoracostomy placement. Study approval was obtained from the Brooke Army Medical Center Institutional Review Board (C.2017.152d). Results: Twenty-five COVID-19 patients and 38 controls were included. Demographic parameters did not differ between the groups. The incidence of pneumothorax was not significantly different between the two groups (44% COVID-19 vs. 22% control, OR 2.8, 95% CI 0.95-7.9, P = 0.09). Patients with COVID-19 were as likely to receive tube thoracostomy as controls (36% vs. 24%, OR 1.8, 95% CI 0.55-5.7). Complications, however, were more likely to occur in the COVID-19 group (89% vs. 33%, OR 16, 95% CI, 1.6-201, P = 0.0498). Conclusions: Tube thoracostomy placement in COVID-19 patients with ARDS requiring V-V ECMO is common, as are complications following initial placement. Clinicians should anticipate the need for re-intervention in this patient population. Small-bore (14Fr and smaller) pigtail catheters appeared to be safe and efficacious in this setting, but further study on tube thoracostomy management in ECMO patients is needed.