(193) Coping with SARS-CoV-2-induced ARDS

Abstract:

Background: For lung transplant candidates, adaptive coping (problem-focused) is associated with favorable outcomes, while maladaptive coping (avoidance, denial) is associated with poorer outcomes such as non-compliance (Christon & Smith, 2022; Taylor et al, 2008). In comparison to transplant candidates with native pulmonary disease, there is a limited understanding of the coping strategies utilized by patients with ARDS across the varying trajectory of their critical illness (Lee et al, 2009). Here, we present a case of SARS-CoV-2-induced ARDS to describe the unique challenges faced by patients with this acquired pulmonary disease undergoing transplant evaluation.

Case: The patient is a 22-year-old pregnant female without prior pulmonary or psychiatric illness admitted for SARS-CoV-2 ARDS requiring VV-ECMO. Her hospital course was complicated by subarachnoid hemorrhage, retroperitoneal bleed, seizure, multiple pneumothorax and repeated infections. Her baby was delivered at 27 weeks by emergency caesarian section. Following 7 months of ECMO Transplant Psychiatry was consulted to optimize transplant candidacy after she was turned down by a transplant center based on maladaptive coping. Following behavioral intervention, active coping strategies were developed, including increased participation in physical and respiratory therapy. ECMO was explanted and she is currently maintained on supportive mechanical ventilation.

Discussion: Extra-corporeal membrane oxygenation (ECMO) can be lifesaving in patients with SARS-CoV-2-induced ARDS, however some patients may still progress to end-stage lung disease (Lindstedt et al, 2021). It is difficult to predict whether lung improvement might be expected after prolonged ECMO, creating an environment of clinical uncertainty. SARS-CoV-2 ARDS is a consequence of acquired lung disease, for which specific pathophysiological and demographic characteristics may elicit profound levels of emotional distress (Taylor et al, 2008). Compared to congenital lung disease, SARS-CoV-2 ARDS represents a phase of acute deterioration in patients who can be otherwise healthy. The emotional demands of this circumstance, in particular for patients in young adulthood, may far exceed the patient’s ability to cope effectively. Addressing specific coping skills can help patients engage in necessary medical treatment and acclimate to their phase of illness.

Conclusions: Lung transplant candidacy selection is a multi-disciplinary process involving evaluation of medical and psychosocial factors (Christon & Smith, 2022). The high psychological burden experienced by patients with SARS-CoV-2 can result in maladaptive coping in the hospital setting. Identifying this distinct behavioral phenotype may offer new insights into areas of risk which may be targets of intervention for patients undergoing transplant evaluation. Conceptualizing these risks in the context of transplant candidacy remains to be explored. Given the increased demand for donor lungs, ethical consideration of transplant candidates must be balanced with the need for psychiatric intervention (Lepper et al, 2021).