Awake Extracorporeal Membrane Oxygenation for COVID-19–induced Acute Respiratory Distress Syndrome

Mang, Sebastian; Reyher, Christian; Mutlak, Haitham; Natanov, Ruslan; Lotz, Christopher; Gill-Schuster, Daniel; Bals, Robert; Danziger, Guy; Meybohm, Patrick; Kühn, Christian; Lepper, Philipp M.; Muellenbach, Ralf Michael; Seiler, Frederik; Metz, Carlos; Rixecker, Torben; Becker, André; Lubitz, Marco; Korboukov, Serguei; Lotz, Hartmut; Omlor, Albert; Tübben, Michael; Mišić, Jovan

doi:10.1164/rccm.202105-1189le

Cited by 21 publications

(21 citation statements)

References 11 publications

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“…Other single case reports also showed promising results [13][14][15]. However, a prospective observational trial on four German ICUs found that out of 18 patients that were treated with awake vv-ECMO implantation, 14 were intubated during the further stay on ICU [16].…”

Section: Discussionmentioning

confidence: 99%

Successful Treatment of a Patient with COVID-19-Induced Severe ARDS, Pneumothorax, and Pneumomediastinum with Awake vv-ECMO Implantation

Umlauf

Eilenberger

Spring

2022

Case Reports in Critical Care

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Management of acute respiratory distress syndrome (ARDS) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is still a challenge for the staff on intensive-care units (ICU’s) around the world. Many of these patients are treated with invasive ventilation. Sometimes, the occurrence of pneumothorax and/or pneumomediastinum can complicate the course of the disease because initiation of invasive ventilation might be fatal in those patients. Venovenous extracorporal membrane oxygenation (vv-ECMO) is increasingly used to prevent patients with severe ARDS from hypoxia. However, clear recommendations for or against the initiation of vv-ECMO in awake patients are currently lacking. We present the case of a 42-year-old patient with COVID-19-associated severe ARDS, pneumothorax, and pneumomediastinum. To preserve sufficient oxygenation and to avoid invasive ventilation, we implanted a vv-ECMO while the patient was awake. The patient recovered and was discharged home 41 days after transfer to our hospital. We therefore suggest that awake implantation of vv-ECMO might be useful in a subgroup of patients with severe ARDS caused by SARS-CoV-2. However, further evidence is needed to verify our hypothesis.

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Section: Discussionmentioning

confidence: 99%

Successful Treatment of a Patient with COVID-19-Induced Severe ARDS, Pneumothorax, and Pneumomediastinum with Awake vv-ECMO Implantation

Umlauf

Eilenberger

Spring

2022

Case Reports in Critical Care

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“…Theoretically, initiating awake ECMO in COVID-19 patients could provide sufficient gas exchange without the need for invasive mechanical ventilation. First cohort studies on an awake ECMO approach for COVID-19 have shown discouraging results, possibly because awake patients are at greater risk of patient self-inflicted lung injury [ 31 ]. Future studies may reveal whether alveolar derecruitment, following vvECMO initiation due to ultraprotective ventilation, outweighs lung damage caused by less protective ventilation strategies.…”

Section: Discussionmentioning

confidence: 99%

Respiratory Physiology of COVID-19 and Influenza Associated Acute Respiratory Distress Syndrome

Kronibus

Seiler

Danziger

et al. 2022

JCM

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Background: There is ongoing debate whether lung physiology of COVID-19-associated acute respiratory distress syndrome (ARDS) differs from ARDS of other origin. Objective: The aim of this study was to analyze and compare how critically ill patients with COVID-19 and Influenza A or B were ventilated in our tertiary care center with or without extracorporeal membrane oxygenation (ECMO). We ask if acute lung failure due to COVID-19 requires different intensive care management compared to conventional ARDS. Methods: 25 patients with COVID-19-associated ARDS were matched to a cohort of 25 Influenza patients treated in our center from 2011 to 2021. Subgroup analysis addressed whether patients on ECMO received different mechanical ventilation than patients without extracorporeal support. Results: Compared to Influenza-associated ARDS, COVID-19 patients had higher ventilatory system compliance (40.7 mL/mbar [31.8–46.7 mL/mbar] vs. 31.4 mL/mbar [13.7–42.8 mL/mbar], p = 0.198), higher ventilatory ratio (1.57 [1.31–1.84] vs. 0.91 [0.44–1.38], p = 0.006) and higher minute ventilation at the time of intubation (mean minute ventilation 10.7 l/min [7.2–12.2 l/min] for COVID-19 vs. 6.0 l/min [2.5–10.1 l/min] for Influenza, p = 0.013). There were no measurable differences in P/F ratio, positive end-expiratory pressure (PEEP) and driving pressures (ΔP). Respiratory system compliance deteriorated considerably in COVID-19 patients on ECMO during 2 weeks of mechanical ventilation (Crs, mean decrease over 2 weeks −23.87 mL/mbar ± 32.94 mL/mbar, p = 0.037) but not in ventilated Influenza patients on ECMO and less so in ventilated COVID-19 patients without ECMO. For COVID-19 patients, low driving pressures on ECMO were strongly correlated to a decline in compliance after 2 weeks (Pearson’s R 0.80, p = 0.058). Overall mortality was insignificantly lower for COVID-19 patients compared to Influenza patients (40% vs. 48%, p = 0.31). Outcome was insignificantly worse for patients requiring veno-venous ECMO in both groups (50% mortality for COVID-19 on ECMO vs. 27% without ECMO, p = 0.30/56% vs. 34% mortality for Influenza A/B with and without ECMO, p = 0.31). Conclusion: The pathophysiology of early COVID-19-associated ARDS differs from Influenza-associated acute lung failure by sustained respiratory mechanics during the early phase of ventilation. We question whether intubated COVID-19 patients on ECMO benefit from extremely low driving pressures, as this appears to accelerate derecruitment and consecutive loss of ventilatory system compliance.

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“…Endotracheal extubation while awake during ECMO has been performed, although data is very limited; 27 in contrast, awake ECMO without intubation in selected highly patients has been associated with potentially worse outcomes in one small cohort. 32 Prone positioning 5 , 33 , 34 and early mobilization 27 appear feasible in patients with COVID-19 requiring ECMO support, however data remains too limited to support specific recommendations. Percutaneous tracheostomy appears to be safe in patients with COVID-19.…”

Section: Clinical Carementioning

confidence: 99%

The Use of Extracorporeal Membrane Oxygenation for COVID-19

Parekh

Abrams

Agerstrand

et al. 2023

Clinics in Chest Medicine

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Awake Extracorporeal Membrane Oxygenation for COVID-19–induced Acute Respiratory Distress Syndrome

Cited by 21 publications

References 11 publications

Successful Treatment of a Patient with COVID-19-Induced Severe ARDS, Pneumothorax, and Pneumomediastinum with Awake vv-ECMO Implantation

Successful Treatment of a Patient with COVID-19-Induced Severe ARDS, Pneumothorax, and Pneumomediastinum with Awake vv-ECMO Implantation

Respiratory Physiology of COVID-19 and Influenza Associated Acute Respiratory Distress Syndrome

The Use of Extracorporeal Membrane Oxygenation for COVID-19

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