Solving a Physiological Conundrum: Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) as a Bridge Strategy in Severe Acute Respiratory Distress Syndrome (ARDS) Complicated by High-Output Bronchopleural Fistula.

Severe community-acquired pneumonia (CAP) may lead to complications such as septic shock, acute respiratory distress syndrome (ARDS), empyema, hydropneumothorax, and bronchopleural fistula, creating major therapeutic challenges. In patients with concomitant ARDS and a high-output bronchopleural fistula, the need for lung-protective ventilation may conflict with the reduction in airway pressures required to promote fistula closure. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) may provide a bridge strategy by allowing ultraprotective ventilation while source control and antimicrobial therapy are pursued. We report the case of a 56-year-old man admitted with septic shock secondary to CAP complicated by empyema and hydropneumothorax. On admission, the patient met criteria for severe ARDS, with a PaO₂/FiO₂ ratio of 87 despite a positive end-expiratory pressure (PEEP) of 10 cmH₂O, and refractory hypoxemic and hypercapnic respiratory failure despite prone positioning. A persistent high-output bronchopleural fistula, associated with a continuous air leak of approximately 3 L/min, further compromised ventilatory management. Due to refractory respiratory failure, VV-ECMO was initiated within 24 hours of admission. During hospitalization, pleural cultures identified Prevotella bivia, followed later by Acinetobacter baumannii, and antimicrobial therapy was subsequently adjusted according to microbiological susceptibility and clinical response. VV-ECMO support enabled ultraprotective ventilation and reduced airflow through the fistulous tract, which was associated with a progressive reduction in fistula output and respiratory and structural recovery. This case highlights the physiological conflict between ARDS ventilation strategies and bronchopleural fistula management. VV-ECMO may provide a useful bridge strategy to facilitate ultraprotective ventilation in carefully selected patients with severe respiratory failure complicated by a high-output air leak and pleural infection, while definitive pleural source control and appropriate antimicrobial therapy are pursued.