Extracorporeal gas exchange in adult respiratory distress syndrome: Associated morbidity and its surgical treatment

Abstract

Extracorporeal carbon dioxide removal (ECCO2-R) over a membrane lung is a new therapy for patients with adult respiratory distress syndrome (ARDS) who frequently suffer from lung complications caused by long-term artificial ventilation and who may require major thoracic surgery. This is a report of 76 patients with severe ARDS who were treated by ECCO2-R. Twenty-six of these 76 patients required thoracotomy: 19 for pneumothorax and pneumatocele, and seven for haemothorax, infected lung necrosis or oesophagotracheal fistula. Most pneumothoraces were bilateral. Ten of these 26 patients required reoperation, usually for extensive persisting alveolar air leaks. Sixteen (62 per cent) of the 26 patients who had a thoracotomy and 22 (44 per cent) of the 50 patients without surgery survived. These results demonstrate that performing a thoracotomy, if necessary, does not diminish the survival chance of high-risk patients with severe ARDS.

Is outcome from ARDS related to the severity of respiratory failure?

“…Obviously, extracorporeal support may offer advantages other than the prevention of terminal hypoxia. Although most groups using ECMO or ECCO 2 R have reported survival rates of about 50% [12][13][14], a figure similar to ours, the only way to define the role of extracorporeal support is to perform a randomized trial. One such trial recently [15] failed to demonstrate a survival benefit associated with ECCO 2 R. Since refractory hypoxaemia is more commonly lethal in patients with pneumonia, these patients may be good candidates for such a study.…”

“…In our study, over a period of more than 2 yrs, only 11 patients died of irreversible respiratory failure. Five of these patients had MOF including coagulation problems, which may be a relative contraindication to extracorporeal techniques [12][13][14][15]. Hence, such techniques would have prevented a terminal hypoxic event in very few patients in the present study.…”

“…Although the fatality rate may have decreased in recent years [1,2], it still ranges 40-70% [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. In a landmark article published in 1985, MONTGOMERY et al [3] reported that, in a series of 47 patients with ARDS, sepsis/multiple organ failure (MOF) was the leading cause of death in these patients, whereas refractory hypoxaemia was responsible for only 16% of mortalities.…”

Extracorporeal techniques in acute respiratory distress syndrome

“…Observed survival rates with this strategy were much higher (48.8%) than previously reported in patients with similar clinical characteristics (9), but in a follow-up randomized controlled trial of ECCO 2 R combined with low frequency positive-pressure ventilation, there was no survival benefit over conventional mechanical ventilation (33% vs. 42%, respectively, P=0.8) (10). Thereafter, a number of observational studies suggested a survival rate ranging from 49-81% (11)(12)(13)(14)(15)(16)(17)(18)(19) for selected patients managed with ECMO for severe ARDS. However, conclusions from these early studies on the efficacy of ECMO for ARDS are limited by study methodology and the use of outdated extracorporeal technology as well as mechanical ventilation practices.…”

Pumpenfreie extrakorporale Lungenunterst�tzung mit arterioven�sem Shunt beim schweren akuten Lungenversagen des Erwachsenen

“…B. [4,9,12,13]), die eine Krankenhausüberlebensrate zwischen 54% [4] und 76% [9] angeben. Die pumpengestützte, venovenöse Membranoxygenierung stellt allerdings ein Verfahren mit erhöhtem personellen und apparativen Aufwand dar, das häufig als "ultima ratio" eingesetzt wird und mit einer Reihe ernsthafter Komplikationen assoziiert sein kann.…”