Got an ECMO today consult for refractory and rapidly progressive hypoxia despite intubation. On my arrival, SpO2 was in 30s and 40s.

CXR and bedside U/S confirmed total left lung atelectasis. Right lung appeared normal on both. It's 2020 so COVID swabs had rightfully been sent and everything had to be done in full gear.

BVM was being administered with PEEP valve at 15 and large tidal volumes breaths.

Based on those findings, the team changed to PEEP 5 and small tidal volume breaths, like 3-4 cc/kg IBW, as the patient's other side seemed like baby lung.

SpO2 improved immediately. Was it R to L shunt due to elevated R sided pressures vs over-peep and over-distention? Who knows? Probably the latter.

Once stabilized, recruitment breaths were attempted, but did nothing so bronch was performed.

Foreign body noted in left main bronchus. Interventional Pulm contacted and took for retrieval bronch. There was no history of choking or aspiration btw, but c'est la vie.

An orange plastic cap was removed safely by one of my Interventional Pulm ninja colleagues.

Learning point: Not all hypoxia is fixed by PEEP. Some needs the opposite. Over-distention and over-PEEP of baby lung renders that lung useless. Use what you have. Think about each patient and their physiology individually.
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