Extracorporeal life support for adults with acute respiratory distress syndrome (original) (raw)
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Critical Care, 2016
Background: Mechanical ventilation with a tidal volume (V T) of 6 mL/kg/predicted body weight (PBW), to maintain plateau pressure (P plat) lower than 30 cmH 2 O, does not completely avoid the risk of ventilator induced lung injury (VILI). The aim of this study was to evaluate safety and feasibility of a ventilation strategy consisting of very low V T combined with extracorporeal carbon dioxide removal (ECCO 2 R). Methods: In fifteen patients with moderate ARDS, V T was reduced from baseline to 4 mL/kg PBW while PEEP was increased to target a plateau pressure-(P plat) between 23 and 25 cmH 2 O. Low-flow ECCO 2 R was initiated when respiratory acidosis developed (pH < 7.25, PaCO 2 > 60 mmHg). Ventilation parameters (V T , respiratory rate, PEEP), respiratory compliance (C RS), driving pressure (DeltaP = V T /C RS), arterial blood gases, and ECCO 2 R system operational characteristics were collected during the period of ultra-protective ventilation. Patients were weaned from ECCO 2 R when PaO 2 /FiO 2 was higher than 200 and could tolerate conventional ventilation settings. Complications, mortality at day 28, need for prone positioning and extracorporeal membrane oxygenation, and data on weaning from both MV and ECCO 2 R were also collected. Results: During the 2 h run in phase, V T reduction from baseline (6.2 mL/kg PBW) to approximately 4 mL/kg PBW caused respiratory acidosis (pH < 7.25) in all fifteen patients. At steady state, ECCO 2 R with an average blood flow of 435 mL/min and sweep gas flow of 10 L/min was effective at correcting pH and PaCO 2 to within 10 % of baseline values. PEEP values tended to increase at V T of 4 mL/kg from 12.2 to 14.5 cmH 2 O, but this change was not statistically significant. Driving pressure was significantly reduced during the first two days compared to baseline (from 13.9 to 11.6 cmH 2 O; p < 0.05) and there were no significant differences in the values of respiratory system compliance. Rescue therapies for life threatening hypoxemia such as prone position and ECMO were necessary in four and two patients, respectively. Only two study-related adverse events were observed (intravascular hemolysis and femoral catheter kinking). Conclusions: The low-flow ECCO 2 R system safely facilitates a low volume, low pressure ultra-protective mechanical ventilation strategy in patients with moderate ARDS.
Extracorporeal Life Support for Severe Acute Respiratory Distress Syndrome in Adults
Transactions of the ... Meeting of the American Surgical Association, 2004
Objective: Severe acute respiratory distress syndrome (ARDS) is associated with a high level of mortality. Extracorporeal life support (ECLS) during severe ARDS maintains oxygen and carbon dioxide gas exchange while providing an optimal environment for recovery of pulmonary function. Since 1989, we have used a protocol-driven algorithm for treatment of severe ARDS, which includes the use of ECLS when standard therapy fails. The objective of this study was to evaluate our experience with ECLS in adult patients with severe ARDS with respect to mortality and morbidity. Methods: We reviewed our complete experience with ELCS in adults from January 1, 1989, through December 31, 2003. Severe ARDS was defined as acute onset pulmonary failure, with bilateral infiltrates on chest x-ray, and PaO 2 /fraction of inspired oxygen (FiO 2 ) ratio Յ100 or A-aDO 2 Ͼ600 mm Hg despite maximal ventilator settings. The indication for ECLS was acute severe ARDS unresponsive to optimal conventional treatment. The technique of ECLS included veno-venous or veno-arterial vascular access, lung "rest" at low FiO 2 and inspiratory pressure, minimal anticoagulation, and optimization of systemic oxygen delivery. Results: During the study period, ECLS was used for 405 adult patients age 17 or older. Of these 405 patients, 255 were placed on ECLS for severe ARDS refractory to all other treatment. Sixty-seven percent were weaned off ECLS, and 52% survived to hospital discharge. Multivariate logistic regression analysis identified the following pre-ELCS variables as significant independent predictors of survival: (1) age (P ϭ 0.01); (2) gender (P ϭ 0.048); (3) pH Յ7.10 (P ϭ 0.01); (4) PaO 2 /FiO 2 ratio (P ϭ 0.03); and (5) days of mechanical ventilation (P Ͻ 0.001). None of the patients who survived required permanent mechanical ventilation or supplemental oxygen therapy.
The Annals of Thoracic Surgery, 2015
Background. Given substantial advances in venovenous extracorporeal membrane oxygenation (ECMO) technology, long-term support is increasingly feasible. Although the benefits of short-term ECMO as a bridge to recovery in acute respiratory distress syndrome (ARDS) are well described, the utility and outcomes of long-term support remain unclear. Methods. Patients requiring ECMO for ARDS between January 2009 and November 2012 were retrospectively reviewed and analyzed separately for those requiring ECMO support for less than 3 weeks or for 3 weeks or longer. Demographic factors, ECMO variables, and outcomes were assessed. Results. Fifty-five patients with ARDS received ECMO during the study period, with 11 patients requiring longterm ECMO support and a median duration of 36 (interquartile range: 24 to 68) days. Recovery was the initial goal in all patients. Pre-ECMO mechanical ventilatory support, indices of disease severity, and the ECMO cannulation strategy were similar between the two groups. Eight (73%) patients receiving long-term support were bridged to recovery, and 1 patient was bridged to transplantation after a refractory course. Eight (73%) patients receiving long-term support and 25 (57%) patients receiving short-term support survived to 30 days and hospital discharge. Conclusions. Previously, long-term ECMO support was thought to be associated with unfavorable outcomes. This study, however, may provide support for the efficacy of ECMO support even for 3 weeks or more as a bridge to recovery or transplantation.
The journal of extra-corporeal technology, 2017
Extracorporeal carbon dioxide removal (ECCO2R) permits reductions in alveolar ventilation requirements that the lungs would otherwise have to provide. This concept was applied to a case of hypercapnia refractory to high-level invasive mechanical ventilator support. We present a case of an 18-year-old man who developed post-pneumonectomy acute respiratory distress syndrome (ARDS) after resection of a mediastinal germ cell tumor involving the left lung hilum. Hypercapnia and hypoxemia persisted despite ventilator support even at traumatic levels. ECCO2R using a miniaturized system was instituted and provided effective carbon dioxide elimination. This facilitated establishment of lung-protective ventilator settings and lung function recovery. Extracorporeal lung support increasingly is being applied to treat ARDS. However, conventional extracorporeal membrane oxygenation (ECMO) generally involves using large cannulae capable of carrying high flow rates. A subset of patients with ARDS h...
Baylor University Medical Center Proceedings, 2019
Venovenous extracorporeal membrane oxygenation (ECMO) has emerged as an important tool in the treatment of acute respiratory distress syndrome (ARDS). The creation of portable ECMO circuits and pumps has supported the development of interfacility ECMO programs. Prior studies have demonstrated that ECMO transport is safe; however, long-term outcomes for these patients remain unknown. Retrospective analysis of our 5-year experience identified 58 patients transported on ECMO and 82 patients cannulated at our institution. When short-term (30 days) and long-term (1 year) outcomes were compared between these cohorts, there was no statistically significant difference in survival (P ¼ 0.44 and 0.49). There were no deaths related to transport, and the rate of ECMO-related complications was similar between the groups. With established patient safety and similar long-term survival, ECMO transport is a feasible solution to provide access to ECMO for all communities.
The Role of Extracorporeal Membrane Oxygenation on Acute Respiratory Distress Syndrome
Bioscientia Medicina : Journal of Biomedicine and Translational Research, 2021
Acute lung injury and acute respiratory distress syndrome are characterized by rapid-onset respiratory failure following a variety of direct and indirect insults to the parenchyma or vasculature of the lungs. Extracorporeal membrane oxygenation is a form of extracorporeal life support where an external artificial circulator carries venous blood from the patient to a gas exchange device (oxygenator) where blood becomes enriched with oxygen and has carbon dioxide removed. This blood then re-enters the patients circulation. The potential advantages of ECMO over conventional manajement may extend beyond its role in supporting patients with ARDS. ECMO may facilitate and enhance the application of lung-protective ventilation by minimizing ventilator-induced lung injury.