Extracorporeal techniques in acute respiratory distress syndrome.
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ABSTRACT:
SUBMITTER: Parekh M
PROVIDER: S-EPMC5537115 | biostudies-other | 2017 Jul
REPOSITORIES: biostudies-other
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Project description:Extracorporeal membrane oxygen (ECMO) has been used for many years in patients with life-threatening hypoxaemia and/or hypercarbia. While early trials demonstrated that it was associated with poor outcomes and extensive haemorrhage, the technique has evolved. It now encompasses new technologies and understanding that the lung protective mechanical ventilation it can facilitate is inextricably linked to improving outcomes for patients. The positive results from the CESAR (Conventional ventilation or ECMO for Severe Adult Respiratory failure) study and excellent outcomes in patients who suffered severe influenza A (H1N1/09) infection have established ECMO in the care of patients with severe acute respiratory distress syndrome. Controversy remains as to at what point in the clinical pathway ECMO should be employed; as a rescue therapy or more pro-actively to enable and ensure high-quality lung protective mechanical ventilation. The primary aims of this article are to discuss: 1) the types of extracorporeal support available; 2) the rationale for its use; 3) the relationship with lung protective ventilation; and 4) the current evidence for its use.
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Project description:Extracorporeal life support (ECLS) can support gas exchange in patients with the acute respiratory distress syndrome (ARDS). During ECLS, venous blood is drained from a central vein via a cannula, pumped through a semipermeable membrane that permits diffusion of oxygen and carbon dioxide, and returned via a cannula to a central vein. Two related forms of ECLS are used. Venovenous extracorporeal membrane oxygenation (ECMO), which uses high blood flow rates to both oxygenate the blood and remove carbon dioxide, may be considered in patients with severe ARDS whose oxygenation or ventilation cannot be maintained adequately with best practice conventional mechanical ventilation and adjunctive therapies, including prone positioning. Extracorporeal carbon dioxide removal (ECCO2R) uses lower blood flow rates through smaller cannulae and provides substantial CO2 elimination (~ 20-70% of total CO2 production), albeit with marginal improvement in oxygenation. The rationale for using ECCO2R in ARDS is to facilitate lung-protective ventilation by allowing a reduction of tidal volume, respiratory rate, plateau pressure, driving pressure and mechanical power delivered by the mechanical ventilator. This narrative review summarizes physiological concepts related to ECLS, as well as the rationale and evidence supporting ECMO and ECCO2R for the treatment of ARDS. It also reviews complications, limitations, and the ethical dilemmas that can arise in treating patients with ECLS. Finally, it discusses future key research questions and challenges for this technology.
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Project description:Neurologic complications following acute respiratory distress syndrome (ARDS) are well described, however, information on the neurologic outcome regarding peripheral nervous system complications in critically ill ARDS patients, especially those who received extracorporeal membrane oxygenation (ECMO) are lacking. In this prospective observational study 28 ARDS patients who survived after ECMO or conventional nonECMO treatment were examined for neurological findings. Nine patients had findings related to cranial nerve innervation, which differed between ECMO and nonECMO patients (p = 0.031). ECMO patients had severely increased patella tendon reflex (PTR) reflex levels (p = 0.027 vs. p = 0.125) as well as gastrocnemius tendon reflex (GTR) (p = 0.041 right, p = 0.149 left) were affected on the right, but not on the left side presumably associated with ECMO cannulation. Paresis (14.3% of patients) was only found in the ECMO group (p = 0.067). Paresthesia was frequent (nonECMO 53.8%, ECMO 62.5%; p = 0.064), in nonECMO most frequently due to initial trauma and polyneuropathy, in the ECMO group mainly due to impairments of N. cutaneus femoris lateralis (4 vs. 0; p = 0.031). Besides well-known central neurologic complications, more subtle complications were detected by thorough clinical examination. These findings are sufficient to hamper activities of daily living and impair quality of life and psychological health and are presumably directly related to ECMO therapy.
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Project description:The acute respiratory distress syndrome (ARDS) is a common cause of respiratory failure in critically ill patients and is defined by the acute onset of noncardiogenic pulmonary oedema, hypoxaemia and the need for mechanical ventilation. ARDS occurs most often in the setting of pneumonia, sepsis, aspiration of gastric contents or severe trauma and is present in ~10% of all patients in intensive care units worldwide. Despite some improvements, mortality remains high at 30-40% in most studies. Pathological specimens from patients with ARDS frequently reveal diffuse alveolar damage, and laboratory studies have demonstrated both alveolar epithelial and lung endothelial injury, resulting in accumulation of protein-rich inflammatory oedematous fluid in the alveolar space. Diagnosis is based on consensus syndromic criteria, with modifications for under-resourced settings and in paediatric patients. Treatment focuses on lung-protective ventilation; no specific pharmacotherapies have been identified. Long-term outcomes of patients with ARDS are increasingly recognized as important research targets, as many patients survive ARDS only to have ongoing functional and/or psychological sequelae. Future directions include efforts to facilitate earlier recognition of ARDS, identifying responsive subsets of patients and ongoing efforts to understand fundamental mechanisms of lung injury to design specific treatments.
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Project description:Acute respiratory distress syndrome (ARDS) is an acute respiratory illness characterised by bilateral chest radiographical opacities with severe hypoxaemia due to non-cardiogenic pulmonary oedema. The COVID-19 pandemic has caused an increase in ARDS and highlighted challenges associated with this syndrome, including its unacceptably high mortality and the lack of effective pharmacotherapy. In this Seminar, we summarise current knowledge regarding ARDS epidemiology and risk factors, differential diagnosis, and evidence-based clinical management of both mechanical ventilation and supportive care, and discuss areas of controversy and ongoing research. Although the Seminar focuses on ARDS due to any cause, we also consider commonalities and distinctions of COVID-19-associated ARDS compared with ARDS from other causes.
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Project description:In the past decade, vaping has become more prevalent globally. Since mid-2019, reports have linked the use of vaping devices to lung injury (EVALI). This is the first reported adult case outside the USA to require ECMO for a severe vaping complication. https://bit.ly/39hf2ZY.
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Project description:A growing body of evidence supports the use of extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) refractory to maximal medical therapy. ARDS may develop in a proportion of patients hospitalized for coronavirus disease 2019 (COVID-19) and ECMO may be used to manage patients refractory to maximal medical therapy to mitigate the risk of ventilator-induced lung injury and provide lung rest while awaiting recovery. The mortality of COVID-19-related ARDS was variously reassessed during the pandemic. Veno-venous (VV) ECMO was the default choice to manage refractory respiratory failure; however, with concomitant severe right ventricular dysfunction, venoarterial (VA) ECMO or mechanical right ventricular assist devices with extracorporeal gas exchange (Oxy-RVAD) were also considered. ECMO has also been used to manage special populations such as pregnant women, pediatric patients affected by severe forms of COVID-19, and, in cases with persistent and seemingly irreversible respiratory failure, as a bridge to successful lung transplantation. In this narrative review, we outline and summarize the most recent evidence that has emerged on ECMO use in different patient populations with COVID-19-related ARDS.
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Project description:Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients treated with V-V ECMO. However, many aspects of the care of patients on V-V ECMO remain debated. In this review, we will focus on main issues and controversies on caring of ARDS patients on V-V ECMO support. Particularly, the indications to V-V ECMO and the feasibility of a less invasive extracorporeal carbon dioxide removal will be discussed. Moreover, the controversies on management of mechanical ventilation, prone position and sedation will be explored. In conclusion, we will discuss evidences on transfusions and management of anticoagulation, also focusing on patients who undergo simultaneous treatment with ECMO and renal replacement therapy. This review aims to discuss all these clinical aspects with an eye on future directions and perspectives.
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Project description:BackgroundCase series have reported favorable outcomes with extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory distress syndrome. However, those patients were generally young, with few comorbid conditions.ObjectiveTo characterize the clinical features and survival rates of patients with severe acute respiratory distress syndrome who met criteria for ECMO but were managed without it.MethodsPatients who met the study criteria were identified prospectively. Inclusion criteria for ECMO included severe hypoxemia, uncompensated hypercapnia, or elevated end-inspiratory plateau pressures despite low tidal volume ventilation. Predicted survival rates with ECMO were calculated using the Respiratory ECMO Survival Prediction score.ResultsOf the 46 patients who met the criteria for severe acute respiratory distress syndrome and ECMO consideration, 5 received ECMO and 16 patients had at least 1 contraindication to it. The remaining 25 patients met ECMO criteria but did not receive the treatment. The patients' mean age was 53.5 (SD, 14.3) years; 84% had at least 1 major comorbid condition. The median predicted survival rate with ECMO was 57%. The actual hospital discharge survival rate without ECMO was 56%.ConclusionsThe general medical intensive care patient population with severe acute respiratory distress syndrome is older and sicker than patients reported in prior case series in which patients were treated with ECMO. In this study, the survival rate without ECMO was similar to predicted survival rates with ECMO.
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