Spontaneous breathing in patients with severe acute respiratory distress syndrome receiving prolonged extracorporeal membrane oxygenation

Abstract Background The use of extracorporeal membrane oxygenation (ECMO) in awake, spontaneously breathing and non-intubated patients (awake ECMO) may be a novel therapeutic strategy for severe acute respiratory distress syndrome (ARDS) patients. The purpose of this study is to assess the feasibility and safety of awake ECMO in severe ARDS patients receiving prolonged ECMO (> 14 days). Methods We describe our experience with 12 consecutive severe ARDS patients (age, 39.1 ± 16.4 years) supported with awake ECMO to wait for native lung recovery during prolonged ECMO treatment from July 2013 to January 2018. Outcomes are reported including the hospital mortality, ECMO-related complications and physiological data on weaning from invasive ventilation. Results The patients received median 26.0 (15.5, 64.8) days of total ECMO duration in the cohort. The longest ECMO support duration was 121 days. Awake ECMO and extubation was implemented after median 10.2(5.0, 42.9) days of ECMO. Awake ECMO was not associated with increased morbidity. The total invasive ventilation duration, lengths of stay in the ICU and hospital in the cohort were 14.0(12.0, 37.3) days, 33.0(22.3, 56.5) days and 46.5(27.3, 84.8) days, respectively. The hospital mortality rate was 33.3% (4/12) in the cohort. Survivors had more stable respiratory rate and heart rate after extubation when compared to the non-survivors. Conclusions With carefully selected patients, awake ECMO is a feasible and safe strategy for severe pulmonary ARDS patients receiving prolonged ECMO support to wait for native lung recovery.

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Comparisons of Outcomes between Patients with Direct and Indirect Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation

Membranes ◽

10.3390/membranes11080644 ◽

2021 ◽

Vol 11 (8) ◽

pp. 644

Author(s):

Li-Chung Chiu ◽

Li-Pang Chuang ◽

Shih-Wei Lin ◽

Hsin-Hsien Li ◽

Shaw-Woei Leu ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Clinical Outcomes ◽

Sofa Score ◽

Distress Syndrome ◽

Cox Regression ◽

Membrane Oxygenation

Acute respiratory distress syndrome (ARDS) is a heterogeneous syndrome caused by direct (local damage to lung parenchyma) or indirect lung injury (insults from extrapulmonary sites with acute systemic inflammatory response), the clinical and biological complexity can have a profound effect on clinical outcomes. We performed a retrospective analysis of 152 severe ARDS patients receiving extracorporeal membrane oxygenation (ECMO). Our objective was to assess the differences in clinical characteristics and outcomes of direct and indirect ARDS patients receiving ECMO. Overall hospital mortality was 53.3%. A total of 118 patients were assigned to the direct ARDS group, and 34 patients were assigned to the indirect ARDS group. The 28-, 60-, and 90-day hospital mortality rates were significantly higher among indirect ARDS patients (all p < 0.05). Cox regression models demonstrated that among direct ARDS patients, diabetes mellitus, immunocompromised status, ARDS duration before ECMO, and SOFA score during the first 3 days of ECMO were independently associated with mortality. In indirect ARDS patients, SOFA score and dynamic compliance during the first 3 days of ECMO were independently associated with mortality. Our findings revealed that among patients receiving ECMO, direct and indirect subphenotypes of ARDS have distinct clinical outcomes and different predictors for mortality.

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Extracorporeal membrane oxygenation for acute respiratory distress syndrome in adults: an analysis of differences between survivors and non-survivors

Perfusion ◽

10.1177/0267659117693075 ◽

2017 ◽

Vol 32 (6) ◽

pp. 495-500 ◽

Cited By ~ 7

Author(s):

Bernd Panholzer ◽

Katrin Meckelburg ◽

Katharina Huenges ◽

Grischa Hoffmann ◽

Michael von der Brelie ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Kidney Injury ◽

Study Data ◽

Adverse Outcomes ◽

Ecmo Support ◽

Membrane Oxygenation

Objectives: Over the last decade, extracorporeal membrane oxygenation (ECMO) has become a promising option for patients with severe acute respiratory distress syndrome (ARDS). In this single-center observational cohort study, data from a patient group with severe ARDS treated with ECMO was analyzed. Methods: Data from 46 patients [median age 54 years (18 to 72), male: 65.2%] were evaluated retrospectively between January 2009 and September 2015. Results: Diagnosis leading to ARDS was pneumonia in 63.1% of the patients. The median SOFA Score was 13 (10 to 19) and the median LIS was 3.5 (2.67 to 4). The median duration of ECMO support was 12 days (1 to 86). Twenty-eight patients (60.9%) were successfully weaned from ECMO and 22 patients survived (47.8%). Non-survivors needed significantly more frequent renal replacement therapy (37.5% vs. 18.2%; p<0.01) and transfusion of red blood cell concentrates [0.4 units (0.3 to 1.2) vs. 0.9 units (0.5 to 1.6); p<0.01] during ECMO support compared to patients who survived. Conclusion: This report suggests that ECMO currently allows treatment of severe ARDS with presumed improved survival. The incidence rate of acute kidney injury and transfusion are associated with adverse outcomes.

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Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome: Propensity Score Matching

Membranes ◽

10.3390/membranes11060393 ◽

2021 ◽

Vol 11 (6) ◽

pp. 393

Author(s):

Li-Chung Chiu ◽

Li-Pang Chuang ◽

Shaw-Woei Leu ◽

Yu-Jr Lin ◽

Chee-Jen Chang ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Mortality Rate ◽

Propensity Score ◽

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Propensity Score Matching ◽

Distress Syndrome ◽

Membrane Oxygenation

The high mortality rate of patients with severe acute respiratory distress syndrome (ARDS) warrants aggressive clinical intervention. Extracorporeal membrane oxygenation (ECMO) is a salvage therapy for life-threatening hypoxemia. Randomized controlled trials of ECMO for severe ARDS comprise a number of ethical and methodological issues. Therefore, indications and optimal timing for implementation of ECMO, and predictive risk factors for outcomes have not been adequately investigated. We performed propensity score matching to match ECMO-supported and non-ECMO-supported patients at 48 h after ARDS onset for comparisons based on clinical outcomes and hospital mortality. A total of 280 severe ARDS patients were included, and propensity score matching of 87 matched pairs revealed that the 90-d hospital mortality rate was 56.3% in the ECMO group and 74.7% in the non-ECMO group (p = 0.028). Subgroup analysis revealed that greater severity of ARDS, higher airway pressure, or a higher Sequential Organ Failure Assessment score tended to benefit from ECMO treatment in terms of survival. Multivariate logistic regression revealed that hospital mortality was significantly lower among patients who received ECMO than among those who did not. Our findings suggested that early initiation of ECMO (within 48 h) may increase the likelihood of survival for patients with severe ARDS.

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Outcomes of Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome in COVID-19 Patients: A Propensity-Matched Analysis

Journal of Clinical Medicine ◽

10.3390/jcm10122547 ◽

2021 ◽

Vol 10 (12) ◽

pp. 2547

Author(s):

Teresa Autschbach ◽

Nima Hatam ◽

Koray Durak ◽

Oliver Grottke ◽

Michael Dreher ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Ecmo Support ◽

Survival Prediction ◽

Historical Cohort ◽

Membrane Oxygenation ◽

Ecmo Therapy

It remains unclear to what extent the outcomes and complications of extracorporeal membrane oxygenation (ECMO) therapy in COVID-19 patients with acute respiratory distress syndrome (ARDS) differ from non-COVID-19 ARDS patients. In an observational, propensity-matched study, outcomes after ECMO support were compared between 19 COVID-19 patients suffering from ARDS (COVID group) and 34 matched non-COVID-19 ARDS patients (NCOVID group) from our historical cohort. A 1:2 propensity matching was performed based on respiratory ECMO survival prediction (RESP) score, age, gender, bilirubin, and creatinine levels. Patients’ characteristics, laboratory parameters, adverse events, and 90-day survival were analyzed. Patients’ characteristics in COVID and NCOVID groups were similar. Before ECMO initiation, fibrinogen levels were significantly higher in the COVID group (median: 493 vs. 364 mg/dL, p < 0.001). Median ECMO support duration was similar (16 vs. 13 days, p = 0.714, respectively). During ECMO therapy, patients in the COVID group developed significantly more thromboembolic events (TEE) than did those in the NCOVID group (42% vs. 12%, p = 0.031), which were mainly pulmonary artery embolism (PAE) (26% vs. 0%, p = 0.008). The rate of major bleeding events (42% vs. 62%, p = 0.263) was similar. Fibrinogen decreased significantly more in the COVID group than in the NCOVID group (p < 0.001), whereas D-dimer increased in the COVID group (p = 0.011). Additionally, 90-day mortality did not differ (47% vs. 74%; p = 0.064) between COVID and NCOVID groups. Compared with that in non-COVID-19 ARDS patients, ECMO support in COVID-19 patients was associated with comparable in-hospital mortality and similar bleeding rates but a higher incidence of TEE, especially PAE. In contrast, coagulation parameters differed between COVID and NCOVID patients.

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Application of veno-venous extracorporeal membrane oxygenation in lymphoma patients with severe acute respiratory distress syndrome

Medicina Fluminensis ◽

10.21860/medflum2021_365343 ◽

2021 ◽

Vol 57 (1) ◽

pp. 109-113

Author(s):

Dorian Tokmadžić ◽

Kazimir Juričić ◽

Matilda Novosel ◽

Alen Protić

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Hodgkin’S Lymphoma ◽

Distress Syndrome ◽

Ecmo Support ◽

Hodgkin's Lymphoma ◽

Membrane Oxygenation ◽

Vv Ecmo

Aim: To report the clinical courses of two patients, one with Hodgkin’s lymphoma (HL) and one with Non-Hodgkin’s lymphoma (NHL), who developed severe refractory acute respiratory distress syndrome (ARDS) and were treated with veno-venous extracorporeal membrane oxygenation (VV ECMO). Case report: Both patients developed chemotherapy-associated febrile neutropenia followed by pneumonia and ARDS, after which they were transferred to the intensive care unit. Their respiratory failure deteriorated despite endotracheal intubation with protective mechanical ventilation, at which point a decision for VV ECMO initiation was made. Both patients had complicated treatment courses and developed severe ECMO-associated complications. The most important complications of ECMO support in our HL patient were cardiac arrest; right atrial laceration with pericardial tamponade which needed surgical treatment; right leg ischemia which required transfemoral amputation; thrombosis within the membrane oxygenator; several septic episodes with severe hemodynamic instability; and right sided tension pneumothorax. Despite all difficulties, the patient was successfully weaned from ECMO. Unfortunately, he died prior to hospital discharge as a result of sepsis with multiple organ failure. The most significant ECMO-induced complications in our NHL patient were severe bleeding incidents, most notably diffuse oropharyngeal and continuous bilateral pulmonary hemorrhage; superimposed bacterial pneumonia; extensive pneumomediastinum and subcutaneous emphysema. Despite all therapeutic efforts, the patient died during ECMO treatment because of respiratory decompensation. Conclusions: The patients with hematologic malignancies (HMs) undergoing ECMO support have poor outcomes, with high rates of severe ECMO-induced complications. Further studies focusing on patient selection and issues concerning prevention, diagnosis and treatment of ECMO-associated complications are needed.

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Cumulative Fluid Balance during Extracorporeal Membrane Oxygenation and Mortality in Patients with Acute Respiratory Distress Syndrome

Membranes ◽

10.3390/membranes11080567 ◽

2021 ◽

Vol 11 (8) ◽

pp. 567

Author(s):

Li-Chung Chiu ◽

Li-Pang Chuang ◽

Shih-Wei Lin ◽

Yu-Ching Chiou ◽

Hsin-Hsien Li ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Fluid Balance ◽

Distress Syndrome ◽

Fluid Overload ◽

Membrane Oxygenation ◽

Cumulative Fluid Balance

Extracorporeal membrane oxygenation (ECMO) is considered a salvage therapy in cases of severe acute respiratory distress syndrome (ARDS) with profound hypoxemia. However, the need for high-volume fluid resuscitation and blood transfusions after ECMO initiation introduces a risk of fluid overload. Positive fluid balance is associated with mortality in critically ill patients, and conservative fluid management for ARDS patients has been shown to shorten both the duration of mechanical ventilation and time spent in intensive care, albeit without a significant effect on survival. Nonetheless, few studies have addressed the influence of fluid balance on clinical outcomes in severe ARDS patients undergoing ECMO. In the current retrospective study, we examined the impact of cumulative fluid balance (CFB) on hospital mortality in 152 cases of severe ARDS treated using ECMO. Overall hospital mortality was 53.3%, and we observed a stepwise positive correlation between CFB and the risk of death. Cox regression models revealed that CFB during the first 3 days of ECMO was independently associated with higher hospital mortality (adjusted hazard ratio 1.110 [95% CI 1.027–1.201]; p = 0.009). Our findings indicate the benefits of a conservative treatment approach to avoid fluid overload during the early phase of ECMO when dealing with severe ARDS patients.

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Mechanical Power During Extracorporeal Membrane Oxygenation and Hospital Mortality in Patients With Acute Respiratory Distress Syndrome

10.21203/rs.3.rs-92705/v1 ◽

2020 ◽

Author(s):

Li-Chung Chiu ◽

Shih-Wei Lin ◽

Li-Pang Chuang ◽

Hsin-Hsien Li ◽

Pi-Hua Liu ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Respiratory System ◽

Distress Syndrome ◽

Mechanical Power ◽

Day Hospital ◽

Membrane Oxygenation

Abstract Background: Mechanical power (MP) refers to the energy delivered by a ventilator to the respiratory system per unit of time. MP normalized to predicted body weight (PBW) or respiratory system compliance have better predictive value for mortality than MP alone in acute respiratory distress syndrome (ARDS). Our objective was to assess the potential impact of consecutive changes of normalized MP on hospital mortality among ARDS patients receiving extracorporeal membrane oxygenation (ECMO).Methods: We performed a secondary analysis of patients with severe ARDS receiving ECMO in a tertiary care referral center in Taiwan between May 2006 and October 2015. Serial changes of MP during ECMO were recorded. Results: A total of 152 patients with severe ARDS rescued with ECMO were analyzed. Overall hospital mortality was 53.3 %. There were no significant differences between survivors and nonsurvivors in terms of baseline values of MP or other ventilator settings. Cox regression models demonstrated that MP alone, MP normalized to PBW, and MP normalized to compliance during the first 3 days of ECMO were all independently associated with hospital mortality. Higher MP normalized to compliance (HR 2.289 [95% CI 1.214-4.314], p = 0.010) was associated with a higher risk of death than MP itself (HR 1.060 [95% CI 1.018-1.104], p = 0.005) or MP normalized to PBW (HR 1.004 [95% CI 1.002-1.007], p < 0.001). The 90-day hospital mortality of patients with high MP (> 14.4 J/min) during the first 3 days of ECMO was significantly higher than that of patients with low MP (≦ 14.4 J/min) (70.7 % versus 46.8 %, p = 0.004), and the 90-day hospital mortality of patients with high MP normalized to compliance (> 0.53 J/min/ml/cm H2O) during the first 3 days of ECMO was significantly higher than that of patients with low MP normalized to compliance (≦ 0.53 J/min/ml/cm H2O) (63.1 % versus 29.5 %, p < 0.001).Conclusions: MP during the first 3 days of ECMO was the only ventilator setting independently associated with 90-day hospital mortality, and MP normalized to compliance during ECMO was more predictive for mortality than was MP alone.

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Mechanical power during extracorporeal membrane oxygenation and hospital mortality in patients with acute respiratory distress syndrome

Critical Care ◽

10.1186/s13054-020-03428-x ◽

2021 ◽

Vol 25 (1) ◽

Author(s):

Li-Chung Chiu ◽

Shih-Wei Lin ◽

Li-Pang Chuang ◽

Hsin-Hsien Li ◽

Pi-Hua Liu ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Respiratory System ◽

Distress Syndrome ◽

Mechanical Power ◽

Day Hospital ◽

Membrane Oxygenation

Abstract Background Mechanical power (MP) refers to the energy delivered by a ventilator to the respiratory system per unit of time. MP referenced to predicted body weight (PBW) or respiratory system compliance have better predictive value for mortality than MP alone in acute respiratory distress syndrome (ARDS). Our objective was to assess the potential impact of consecutive changes of MP on hospital mortality among ARDS patients receiving extracorporeal membrane oxygenation (ECMO). Methods We performed a retrospective analysis of patients with severe ARDS receiving ECMO in a tertiary care referral center in Taiwan between May 2006 and October 2015. Serial changes of MP during ECMO were recorded. Results A total of 152 patients with severe ARDS rescued with ECMO were analyzed. Overall hospital mortality was 53.3%. There were no significant differences between survivors and nonsurvivors in terms of baseline values of MP or other ventilator settings. Cox regression models demonstrated that mean MP alone, MP referenced to PBW, and MP referenced to compliance during the first 3 days of ECMO were all independently associated with hospital mortality. Higher MP referenced to compliance (HR 2.289 [95% CI 1.214–4.314], p = 0.010) was associated with a higher risk of death than MP itself (HR 1.060 [95% CI 1.018–1.104], p = 0.005) or MP referenced to PBW (HR 1.004 [95% CI 1.002–1.007], p < 0.001). The 90-day hospital mortality of patients with high MP (> 14.4 J/min) during the first 3 days of ECMO was significantly higher than that of patients with low MP (≦ 14.4 J/min) (70.7% vs. 46.8%, p = 0.004), and the 90-day hospital mortality of patients with high MP referenced to compliance (> 0.53 J/min/ml/cm H2O) during the first 3 days of ECMO was significantly higher than that of patients with low MP referenced to compliance (≦ 0.53 J/min/ml/cm H2O) (63.6% vs. 29.7%, p < 0.001). Conclusions MP during the first 3 days of ECMO was the only ventilatory variable independently associated with 90-day hospital mortality, and MP referenced to compliance during ECMO was more predictive for mortality than was MP alone.

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Prone Position Ventilation for Pediatric Acute Respiratory Distress Syndrome with Extracorporeal Membrane Oxygenation: A Propensity Score-Matched Retrospective Multicenter Cohort Study

10.21203/rs.3.rs-129358/v1 ◽

2020 ◽

Author(s):

Zhe Zhao ◽

Guoping Lu ◽

Shuanglei Li ◽

Baowang Yang ◽

Huiling Zhang ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Propensity Score ◽

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Prone Position ◽

Distress Syndrome ◽

Membrane Oxygenation ◽

Oxygen State

Abstract Background: Extracorporeal membrane oxygen (ECMO) has used for rescuing severe pediatric acute respiratory distress syndrome (PARDS) for half a century. Prone position ventilation (PPV) has been suggested according to the surviving sepsis campaign (SSC) guideline in children in 2020. We aimed to compare the outcomes and effect of PARDS patients with ECMO+PPV and ECMO only.Design: Retrospective Multicenter pair-matched StudySetting: In the present study, propensity score matching was conducted and the outcomes of severe PARDS patients were analyzed. The effect of PPV was compared as well. The efficiency of PPV included PaO2, Oxygen Index (OI), PaO2/FiO2, compliance of respiratory system and resistance of airway. The primary outcome was hospital mortality. Secondary outcomes included ECMO running time, PICU time, hospital days and mechanical ventilation time of survivors. Patients: 137 PARDS patients with criteria of ECMO from 11 hospitals in 5 years.Interventions: No interventions.Measurements and Main Results: Among 137 patients, 93 patients received ECMO+PPV at the same time and 44 patients didn’t. After matching, we got 34 pairs. For the survivors receiving ECMO+PPV, the PaO2, OI and PaO2/FiO2 increased significantly during the PPV period (P<0.01) and sustained for 4 hours at least. However, the hospital mortality of both groups showed no significant difference (50.0 vs. 55.9%, P=0.808). Conclusions: By far, there has been no ECMO+PPV efficiency study in PARDS patients. This study found that PPV was associated with improved oxygen state during ECMO. However, PPV was not associated with survival rate with PARDS patients on ECMO. Clinical Trial Registration: This study was registered at http://www.chictr.org.cn/index.aspx (chiCTR.gov; Identifier: ChiCTR1800019555). Registered 18 November 2018. Name of the registry: Extracorporeal membrane oxygenation in critical ill children with severe acute respiratory distress syndrome - A multicenter study.Take Home Message:1. Our study investigated prone position ventilation (PPV) could improve the oxygen state during ECMO for patients with severe PARDS.2. The results indicated PPV had no influence on the mortality of PARDS with ECMO.

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