Fig. 1

Consecutive CT images showing subsequent phases in the disease course. a CT scan performed in the referring academic hospital. ECMO, chest tube and tracheostomy tube in situ; the patient was not ventilated, since lung protective settings failed to produce significant tidal volumes. The scan shows bilateral atelectasis, a right-sided bronchopleural fistula, consolidations, destroyed lung parenchyma and a right-sided pneumothorax. b CT scan after ICU discharge and first APRV period. VV-ECMO has been removed; chest tube and tracheostomy in situ. The APRV mode was set and adjusted by the TCAV™ method with auto-release mode set at 75%. Tidal volumes increased and FiO2 could be decreased during recovery of lung parenchyma. Although the lungs are opened, there are persisting parenchymatic abnormalities of both lungs and persisting air leakage via the bronchopleural fistula. c CT scan after surgery for right bronchopleural fistula closure. Chest tube and tracheostomy in situ. Pleural effusion is visible after unsuccessful right-sided bronchopleural fistula closure, as well as a persisting pneumothorax. APRV was then restarted. d CT scan after second discharge and APRV period. Chest tube and tracheostomy in situ. Significant improvement of lung parenchyma is seen after reinstitution of APRV