Sand aspiration managed with extracorporeal membrane oxygenation and a mechanical insufflation-exsufflation device: A case report

We present a case of a class 3 drowning event with severe sand aspiration, successfully managed with mechanical ventilation, bronchoalveolar lavage, ECMO, and the use of a mechanical insufflation-exsufflation device (MI-E). Sand aspiration is a potentially lethal consequence of near-drowning events. It may cause respiratory failure by several mechanisms, including laryngospasm, upper or lower airway obstruction and an intrinsic acute respiratory distress syndrome (ARDS) related to the sand itself. Its standard management involves lung-protective mechanical ventilation strategies, bronchoalveolar lavage, and, more recently, extracorporeal membrane oxygenation (ECMO) in adult and paediatric cases. MI-E devices are commonly used by physiotherapists in the intensive care setting to facilitate secretion clearance in extubated patients, reducing the occurrence of ventilator-associated pneumonia. However, their use in intubated patients in the UK is not as common due to a lack of evidence and experience. The evidence supporting their use in intubated patients is of low quality, and we have not found any examples of their use for clearing aspirated particulate matter or in conjunction with ECMO in the literature. We believe this is the first time MI-E has been used this way. We argue that it could be a valuable addition to the management of sand and other particulate aspirations, even in severe cases requiring ECMO, and it warrants further exploration. Using a MI-E device may significantly decrease the duration of ECMO treatment, reducing its associated complications and expenses.