Rescue strategies combining ultra-protective ventilation and veno-venous ECMO in a patient with near-drowning-related severe ARDS: a case report and literature review

BACKGROUND: Drowning can lead to acute respiratory distress syndrome (ARDS), which is associated with high mortality and poses substantial clinical management challenges. Ultra-protective ventilation strategy combined with veno-venous extracorporeal membrane oxygenation (VV-ECMO) present a viable alternative, yet evidence supporting these strategies in drowning-related ARDS patients remains scarce. CASE PRESENTATION: This case report describes an 18-year-old female who experienced cardiac arrest following near-drowning. After the return of spontaneous circulation, the patient developed severe pulmonary edema leading to ARDS. VV-ECMO was initiated, resulting in a significant improvement in the Horowitz coefficient. Using a combination of VV-ECMO and an ultra-protective ventilation strategy with a lowest tidal volume of 2.8 ml/kg (predicted body weight, PBW), the patient's lung condition improved significantly. Static lung compliance rose from 11 ml/cm H₂O to 46 ml/cm H₂O. The patient was successfully weaned from VV-ECMO on Day 15, extubated on Day 27, and eventually discharged with no obvious pulmonary sequelae. CONCLUSION: The present case indicate that combining ultra-protective ventilation and VV-ECMO may be an effective approach for managing severe near-drowning-related ARDS by improving lung function and increasing the likelihood of successful extubation. This strategy minimizes ventilator-induced lung injury (VILI) while optimizing oxygenation, providing a new perspective for treating similar patients. Further studies are needed to validate its efficacy and optimize treatment protocols.