Multi-faceted Approach to Severe Necrotizing Pneumonia: Integration of V-VECMO and Surgical Intervention in the Management of Empyema and Cor Pulmonale

Background: Severe necrotizing pneumonia (NP) is a life-threatening condition frequently complicated by acute respiratory failure, sepsis, and pulmonary vascular dysfunction.Management becomes particularly challenging when associated with acute cor pulmonale and empyema.Case description: A 33-year-old man presented with a 2-day history of fever, productive cough, and rapidly progressive dyspnea.Initial imaging revealed right middle-zone infiltrates.Shortly after admission, he deteriorated rapidly, requiring endotracheal intubation and prone ventilation.He developed severe lung stiffness, refractory shock requiring vasopressors, and worsening lactic acidosis.Point-of-care ultrasound demonstrated acute cor pulmonale with right atrial and ventricular dilatation and a TAPSE of 0.8 cm.With a Murray score of 3 and a RESP score of -3, veno-venous extracorporeal membrane oxygenation (V-VECMO) was initiated.Bronchoalveolar lavage was positive for COVID-19 and multidrug-resistant Klebsiella.Chest imaging revealed a right hydropneumothorax with empyema requiring intercostal drainage.Over the ensuing days, hemodynamics and right ventricular function improved, allowing gradual weaning from ECMO and successful decannulation on day 11.High-resolution CT (HRCT) later demonstrated extensive NP with complete right-lung collapse and cavitary consolidation, necessitating tracheostomy and video-assisted thoracic surgery.His course was complicated by bronchopleural fistula, critical illness neuromyopathy, and cachexia.Despite persistent right-lung collapse, oxygenation gradually stabilized, enabling ventilator liberation.He was transferred out of the ICU after 28 days and discharged to rehabilitation after a 46-day hospital stay.Conclusion: This case highlights the pivotal role of V-VECMO in stabilizing severe respiratory failure complicated by acute cor pulmonale and empyema in NP.Perseverance and a multimodal management strategy were key to achieving survival in an otherwise fatal clinical scenario.