What question did this study set out to answer?

To assess the effectiveness of early venous-venous extracorporeal membrane oxygenation (VV-ECMO) in a patient with severe ARDS caused by EVALI and Legionnaire's disease.

May 20, 2026

C48-42 Early Initiation of ECMO In Severe ARDS: A Case of Legionella Pneumonia Complicated by EVALI

Key Points

To assess the effectiveness of early venous-venous extracorporeal membrane oxygenation (VV-ECMO) in a patient with severe ARDS caused by EVALI and Legionnaire's disease.
Case presentation of a 48-year-old female with severe ARDS due to EVALI and Legionella pneumonia.
Initiated on NIPPV, high-dose steroids, and broad-spectrum antibiotics before VV-ECMO after 12 hours due to worsened oxygenation.
Clinical outcomes were tracked following VV-ECMO initiation, including timelines for decannulation and extubation.
Rapid clinical improvement on ECMO, with decannulation achieved by hospital day 3 and extubation by hospital day 5.
Confirmed positivity for Legionella pneumophila, leading to a tailored antibiotic treatment with levofloxacin, which supported recovery.
Early initiation of VV-ECMO contributed to reduced ventilator time and minimized lung injury, supporting existing literature.

Abstract

Abstract Introduction Venous-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) is often used in cases of severe hypoxemic respiratory failure to enable gas exchange, minimize ventilator-associated lung injury, and reduce mortality by early initiation. Routine use in ARDS is well described, but data is limited regarding ECMO in E-cigarette or Vaping Associated Lung Injury (EVALI) and Legionnaire’s disease due to their typically non-fulminant course. We present a case of severe ARDS due to EVALI, complicated by Legionnaire’s disease, requiring early VV-ECMO with prompt clinical recovery. Case Presentation A 48-year-old female with history of chronic obstructive pulmonary disease, daily tobacco use, and e-cigarette use presented for encephalopathy and respiratory distress. In the ED, she was tachycardic, tachypneic, and hypoxic. Arterial blood gas revealed respiratory acidosis with hypercapnia. Chest CT angiography showed diffuse bilateral pulmonary opacities. She was admitted to the ICU for presumed EVALI-induced severe ARDS and started on NIPPV, high-dose steroids, and empiric broad-spectrum antibiotics. Oxygenation status worsened despite maximal NIPPV support necessitating intubation and cannulation for VV ECMO within 12 hours of admission. Respiratory panel was positive for Legionella pneumophila and antibiotics were tailored to levofloxacin from azithromycin. There was rapid clinical and radiographic improvement on ECMO with decannulation on hospital day 3 and extubation on hospital day 5. Discussion This case highlights early VV-ECMO as a lifesaving intervention in ARDS secondary to EVALI. Our patient met criteria for early VV-ECMO due to profound hypoxemia and acidosis despite maximal NIPPV support. Her swift clinical recovery supports evidence of early ECMO initiation. The case highlights the importance of appropriate antimicrobial therapy, specifically levofloxacin, which offers superior intracellular penetration and bactericidal activity against Legionella compared to azithromycin with improved clinical outcomes. Data on ECMO in EVALI with Legionnaire’s disease is limited; this case contributes to the evolving literature and supports existing literature guidelines recommending early ECMO initiation to reduce ventilator time, minimize lung injury, and improve survival in fulminant ARDS. This abstract is funded by: None

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