Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications

Abstract

t is estimated that nearly 2 million people with acute respiratory failure are hospitalized annually in the United States at a cost exceeding $50 billion. 1 Approximately half require invasive mechanical ventilation, and in-hospital mortality exceeds 20% in these patients. 1 Mechanical ventilation has been the primary management tool for patients with acute respiratory failure since the 1950s' polio epidemic, yet it is associated with major complications that can increase mortality. 2 Consequently, there is a need for better ventilatory strategies, as well as alternative modes of respiratory support. In this setting, extracorporeal life support (ECLS), which provides gas exchange via an extracorporeal circuit, is increasingly being used to provide support to failing lungs, a failing heart, or both (Figure 1).Rudimentary versions of ECLS developed in the 1970s were used for several decades but were largely abandoned because they lacked compelling evidence for their efficacy and resulted in major complications. 3,4 However, improvements in technology renewed interest in ECLS. 5 Over the last decade, use of ECLS has substantially increased (eFigure, A in the Supplement), at times, far outpacing the evidence justifying its use. [5][6][7] An increasing evidence base now supports greater use of ECLS for adult patients in respiratory failure. [8][9][10][11] This review examines the reemergence of ECLS, discussing the physiologic rationale, current evidence, indications, and complications associated with its use in adult patients with respiratory failure and other related conditions. Importantly, ethical IMPORTANCE The substantial growth over the last decade in the use of extracorporeal life support for adults with acute respiratory failure reveals an enthusiasm for the technology not always consistent with the evidence. However, recent high-quality data, primarily in patients with acute respiratory distress syndrome, have made extracorporeal life support more widely accepted in clinical practice.OBSERVATIONS Clinical trials of extracorporeal life support for acute respiratory failure in adults in the 1970s and 1990s failed to demonstrate benefit, reducing use of the intervention for decades and relegating it to a small number of centers. Nonetheless, technological improvements in extracorporeal support made it safer to use. Interest in extracorporeal life support increased with the confluence of 2 events in 2009:(1) the publication of a randomized clinical trial of extracorporeal life support for acute respiratory failure and (2) the use of extracorporeal life support in patients with severe acute respiratory distress syndrome during the influenza A(H1N1) pandemic. In 2018, a randomized clinical trial in patients with very severe acute respiratory distress syndrome demonstrated a seemingly large decrease in mortality from 46% to 35%, but this difference was not statistically significant. However, a Bayesian post hoc analysis of this trial and a subsequent meta-analysis together suggested that extracorporeal life suppo...

Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases

“…Most importantly, there is now substantially more evidence to support the efficacy and safety of ECMO in patients with ARDS than during previous outbreaks. [11][12][13][14] Although during the 2009 influenza A(H1N1) pandemic few ECMO centres were included in the Extracorporeal Life Support Organization (ELSO) registry of active centres (figure 1), 15 many were urgently established during the outbreak. Notably, despite a steady increase in ELSO-registered centres, there are many centres that are still not registered, which makes it challenging to assess the actual global ECMO capacity and capability.…”

Preparing for the Most Critically Ill Patients With COVID-19

“…2 ECMO is a form of modified cardiopulmonary bypass in which venous blood is removed from the body and pumped through an artificial membrane lung in patients who have refractory respiratory or cardiac failure. 5 Oxygen is added, carbon dioxide is removed, and blood is returned to the patient, either via another vein to provide respiratory support or a major artery to provide circulatory support. ECMO is a resource-intensive, highly specialized, and expensive form of life support with the potential for significant complications, in particular hemorrhage and nosocomial infection.…”

O Coração e a COVID-19: O que o Cardiologista Precisa Saber

“…45,46 At first, venovenous ECMO is indicated for recovery of pulmonary function. 46,47 When associated with significant cardiovascular impairment in patients with severe ventricular dysfunction and/or cardiogenic shock, venoarterial ECMO might be considered. 48 ECMO should be initiated before the installation of failure of multiple organs.…”