Characteristics of Patients Managed without Positive Pressure Ventilation While on Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome

Abstract

Background: Extracorporeal membrane oxygenation (ECMO) has expanding indications for cardiopulmonary resuscitation including severe acute respiratory distress syndrome (ARDS). Despite the adjunct of ECMO for patients with severe ARDS, they often have prolonged mechanical ventilation and are subject to many of its inherent complications. Here, we describe patients who were cannulated for venovenous (VV) ECMO and were taken off positive pressure ventilation. Methods: This is a primary analysis of patients admitted at a tertiary medical center between the dates of August 2014 to January 2020 who were cannulated to ECMO for refractory respiratory failure. We included all patients ≥18 years old. Patients who were extubated or had a tracheostomy and taken off positive pressure while on ECMO were classified as “off positive pressure ventilation (PPV)” and were compared to patients who remained “on PPV” while on ECMO. Primary outcome was survival to hospital discharge. Secondary outcomes were ventilator free days at 30 days and 60 days after ECMO cannulation, time from cannulation to date of first out-of-bed (OOB), and hospital length of stay (LOS). Patient characteristics were derived from routine clinical information in the electronic health record (EHR). Categorical characteristics were compared using chi-square test or Fisher exact test. Continuous characteristics were compared using independent samples t-test or Wilcoxon–Mann–Whitney test. p-values were reported from all analysis. Results: Sixty-five patients were included in this retrospective analysis. Forty-eight were managed on ECMO with PPV and 17 patients were removed from PPV. Patients removed from PPV had significantly higher lung injury scores prior to cannulation (2.5 ± 0.6 vs. 1.04 ± 0.3; p = 0.031) and non-significantly longer duration of ventilation prior to ECMO (6.1 days ± 2.1 vs. 5.0 days ± 01.1; p = 0.634). One hundred percent (100%) of patients removed from PPV survived to hospital discharge compared to 45% who received PPV throughout their duration of ECMO management (p < 0.001). The mean ventilator free days at day 60 was 15 with PPV and 36 without PPV (p = 0.003). The average duration from cannulation to mobilization (i.e., out-of-bed) was 18 days with PPV and 7 days without PPV (p = 0.015). Conclusions: Patients taken off PPV while on ECMO had a very high likelihood of survival to discharge and were mobilized in half as many days. While this likely reflects patient selection, the benefit of early mobilization is well documented and the approach of extubating while on ECMO warrants further investigation.

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

“…A total of 1,157 adult patients undergoing Awake ECLS strategy, described in studies published between 2012 and 2020, were included in the final analysis (Table 1). Main indications for ECLS support were BTR (n = 666, 36.6%) 19,[22][23][24][25][27][28][29][30][31][33][34][35]37,39,41,[43][44][45][46] and BTT (n = 472, 34.8%). 14,21,23,24,26,28,32,[35][36][37][38]40,42,[45][46][47] 14,34,38,39,41,46 and ranged 20-30.1.…”

Tidal volume significantly affects oxygenation in healthy pigs during high-frequency oscillatory ventilation compared to conventional ventilation

“…Clinicians are studying new techniques and approaches. Effect of extracorporeal membrane oxygenation [ 28 , 29 ], different levels of PEEP [ 30 ], prone positioning [ 31 , 32 ], respiratory system impedance analysis [ 33 ], and different times of weaning [ 34 ] has been studied. For the use of HFOV in the treatment of ARDS, there is a need to understand the place of HFOV in the spectrum of diagnostic and therapeutic techniques for severe ARDS care and to define the optimal HFOV strategy [ 35 ].…”

Venovenous extracorporeal membrane oxygenation in obese patients

“…The potential advantages of liberating VV ECMO patients from mechanical ventilation include earlier mobilization, decreased sedation requirements, improved mentation, and improved respiratory muscle usage. 43 This would also apply to those with class 2 or 3 obesity. We would, however, caution against using these patients as the first cohort for trialing ECMO without a mechanical ventilator.…”