Awake extracorporeal life support and physiotherapy in adult patients: A systematic review of the literature

Abstract

Objective The Awake Extracorporeal Life Support (ECLS) practice combined with physiotherapy is increasing. However, available evidence for this approach is limited, with unclear indications on timing, management, and protocols. This review summarizes available literature regarding Awake ECLS and physiotherapy application rates, practices, and outcomes in adults, providing indications for future investigations. Methods Four databases were screened from inception to February 2021, for studies reporting adult Awake ECLS with/without physiotherapy. Primary outcome was hospital discharge survival, followed by Extracorporeal Membrane Oxygenation (ECMO) duration, extubation, Intensive Care Unit stay. Results Twenty-nine observational studies and one randomized study were selected, including 1,157 patients (males n = 611/691, 88.4%) undergoing Awake ECLS. Support type was reported in 1,089 patients: Veno-Arterial ECMO (V-A = 39.6%), Veno-Venous ECMO (V-V = 56.8%), other ECLS (3.6%). Exclusive upper body cannulation and femoral cannulation were applied in 31% versus 69% reported cases ( n = 931). Extubation was successful in 63.5% ( n = 522/822) patients during ECLS. Physiotherapy details were given for 676 patients: exercises confined in bed for 47.9% ( n = 324) patients, mobilization until standing in 9.3% ( n = 63) cases, ambulation performed in 42.7% ( n = 289) patients. Femoral cannulation, extubation and V-A ECMO were mostly correlated to complications. Hospital discharge survival observed in 70.8% ( n = 789/1114). Conclusion Awake ECLS strategy associated with physiotherapy is performed regardless of cannulation approach. Ambulation, as main objective, is achieved in almost half the population examined. Prospective studies are needed to evaluate safety and efficacy of physiotherapy during Awake ECLS, and suitable patient selection. Guidelines are required to identify appropriate assessment/evaluation tools for Awake ECLS patients monitoring.

Extracorporeal Membrane Oxygenation Without Invasive Ventilation for Respiratory Failure in Adults: A Systematic Review*

“…A recent systematic review on physiotherapy during awake extracorporeal life support (ECLS), including 56% of cases of venovenous ECMO, reported a 63% of success rate in successful extubation during ECLS, which is consistent with our findings (78). Compared with this study, our systematic review focuses on patients with respiratory failure, is more updated, and include data on reasons for failure of awake ECMO and major complications.…”

Rehabilitation for adult patients undergoing extracorporeal membrane oxygenation

“…It is now widely accepted that rehabilitation is a standard of care, and researchers may want to explore new directions in this field. Although several studies have shown that mobilization and exercise are possible for patients on ECMO support, 14,15,[23][24][25]27,28,48 their rehabilitative potential is still underestimated at present. 49 On the other hand, implementing early and active rehabilitation is a well-established concept in critically ill patients and ICU settings, although the definition of "early" and the dosage of mobilization remain controversial and uncertain.…”

“…[17][18][19][20][21][22] The first consensus document on physiotherapy for this class of patients was published in 2017, providing evidence-based support for rehabilitation professionals. 23 Since then, various studies have explored rehabilitation methods for patients undergoing ECMO, 14,15,[24][25][26][27] while a recent EuroELSO survey was designed to capture modalities and characteristics of the physiotherapeutic treatments currently provided in international ECMO settings. 28 Rehabilitation of patients on ECMO support involves a complex delivery of assessment procedures and techniques aiming at restoring or maintaining neuromuscular, cognitive and respiratory functions in an acute context of reduced or absent mobility of the person.…”

“…However, current information on the latest rehabilitative practices is limited, as previous reviews covered data up to October 2021, and some considered only patients on awake ECMO or with COVID-19. 15,24,25 Therefore, the present review aims to provide a concise overview of the latest findings on rehabilitation and highlight emerging rehabilitative trends in patients undergoing ECMO support.…”

State of the art: Monitoring of the respiratory system during veno-venous extracorporeal membrane oxygenation

“…The simplest clinical assessment of respiratory drive is to ask the patient. The 11-point modified Borg dyspnoea scale functions similarly to a visual analogue scale 132 and is well validated in conventional ventilation 133,134 and ECMO [135][136][137] The Borg score is also readily repeated allowing changes in native lung and membrane function to be tracked. Most ECMO-supported patients are not able to self-report dyspnoea and so this must be inferred by other means.…”