Extracorporeal Membrane Oxygenation for Adult Respiratory Failure

Peek, Giles J.; Moore, H. M.; Moore, Nick; Sosnowski, Andrzej; Firmin, Richard K.

doi:10.1378/chest.112.3.759

Cited by 230 publications

(143 citation statements)

References 14 publications

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“…During the H1N1 pandemic, a surge in ECLS use in highly selected patients yielded promising results, leading to a resurgence of interest in its use for severe ARDS. The recently completed Conventional ventilatory support versus Extracorporeal membrane oxygenation for Severe Adult Respiratory failure (CESAR) trial and a systematic review of ECLS for the H1N1 cohort further strengthened its potential role as rescue therapy in ARDS (12,13). However, poor outcomes from historical trials and conflicting results from recent reports have tempered the recent enthusiasm for its use and have reestablished clinical equipoise for ECLS in patients with ARDS (14,15).…”

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confidence: 99%

Extracorporeal Life Support for Acute Respiratory Failure. A Systematic Review and Metaanalysis

et al. 2014

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Rationale: Extracorporeal life support (ECLS) for acute respiratory failure has increased as a result of technological advancements and promising results from recent studies as compared with historical trials.Objectives: Systematically review the effect of ECLS compared with mechanical ventilation on mortality, length of stay, and adverse events in respiratory failure.Methods: Data sources included were MEDLINE, EMBASE, and CENTRAL (through to October 2013). Any randomized controlled trial (RCT) or observational study comparing ECLS to mechanical ventilation in adults was used. Two authors independently abstracted the data. Our primary outcome was mortality. Secondary outcomes included intensive care unit length of stay, hospital length of stay, and adverse events. A sensitivity analysis was performed restricted to RCTs and quasi-RCTs, and a number of predefined subgroups were identified to explore heterogeneity. Measurements and Main Results:Ten studies (four RCTs, six observational studies, 1,248 patients) were included. There was no significant difference in hospital mortality with ECLS as compared with mechanical ventilation (risk ratio [RR], 1.02; 95% confidence interval [CI], 0.79-1.33; I 2 = 77%). When restricted to venovenous ECLS studies of randomized trials and quasi-randomized trials (three studies; 504 patients), there was a decrease in mortality with ECLS compared with mechanical ventilation (RR, 0.64; 95% CI, 0.51-0.79; I 2 = 15%). There were insufficient study-level data to evaluate most secondary outcomes. Bleeding was significantly greater in the ECLS group (RR, 11.44; 95% CI, 3.11-42.06; I 2 = 0%). In the H1N1 subgroup (three studies; 364 patients), ECLS was associated with significantly lower hospital mortality (RR, 0.62; 95% CI, 0.45-0.8; I 2 = 25%).Conclusions: ECLS was not associated with a mortality benefit in patients with acute respiratory failure. However, a significant mortality benefit was seen when restricted to higher-quality studies of venovenous ECLS. Patients with H1N1-acute respiratory distress syndrome represent a subgroup that may benefit from ECLS. Future studies are needed to confirm the efficacy of ECLS as well as the optimal configuration, indications, and timing for adult patients with respiratory failure.

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confidence: 99%

Extracorporeal Life Support for Acute Respiratory Failure. A Systematic Review and Metaanalysis

et al. 2014

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“…The benefit of ECMO in the presence of multiorgan failure is dramatically attenuated, and ECMO is associated with poor outcomes in patients who have already been mechanically ventilated for >10 to 14 days at the time of cannulation. 8,9 Patients on ECMO require therapeutic-dose anticoagulation to prevent thrombosis in the setting of indwelling prosthetic tubing and extracorporeal circulation. Hence, ECMO is usually contraindicated in patients with contraindications to anticoagulation, including active bleeding, recent noncardiothoracic surgery, or a hemorrhagic intracranial event.…”

Section: Contraindicationsmentioning

confidence: 99%

Extracorporeal Membrane Oxygenation in Adults With Cardiogenic Shock

et al. 2015

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A 28-year-old previously healthy woman was brought to the hospital after out-of-hospital resuscitated cardiac arrest attributable to ventricular fibrillation. On the evening of presentation, she was found unconscious at home by family members. Bystander cardiopulmonary resuscitation (CPR) was immediately initiated. The patient was defibrillated in the field by emergency medical response providers with return of spontaneous circulation. She aspirated during intubation in the field, and arrived to the hospital in shock, with blood pressure 88/71 mm Hg on norepinephrine 20 μg/min and vasopressin 0.04 U/min. She did not have purposeful movements, and therapeutic hypothermia was initiated in the Emergency Department. She had a metabolic acidosis and concomitant type I acute respiratory failure, with PaO 2 66 mm Hg on volume-cycled assist/control mode with tidal volumes of 400 cc, FiO 2 1.0, positive end-expiratory pressure 10 cm H 2 O, and a respiratory rate of 26 breaths/min. Her ECG did not demonstrate stigmata of ischemia or infarction. However, a type I Brugada pattern was noted in leads V1 and V2 before cooling.Over the ensuing several hours, vasopressor requirements escalated. A SwanGanz catheter demonstrated severely depressed cardiac index and elevated pulmonary capillary wedge pressure. She remained severely hypoxic despite maximal ventilator support. Chest x-ray showed diffuse bilateral pulmonary infiltrates, consistent with severe aspiration pneumonitis. PaO 2 decreased to 49 mm Hg despite increased positive end-expiratory pressure and chemical paralysis, meeting Berlin criteria for severe acute respiratory distress syndrome. 1 Options for percutaneous hemodynamic support were considered (including extracorporeal membrane oxygenation [ECMO] or percutaneous ventricular assist device [VAD], such as Impella and TandemHeart), and the patient was placed on veno-arterial ECMO (VA ECMO) for both hemodynamic and respiratory rescue 6 hours after presentation.Cardiopulmonary bypass was first developed in 1954 to facilitate openheart surgery and used successfully 1 year later. 2,3 Although substantially different from early cardiopulmonary bypass systems, ECMO evolved from cardiopulmonary bypass and provides prolonged cardiopulmonary support outside of the operating suite. With increasing technological advances and safety, the uses of ECMO have expanded, with increasing interest as combined shortterm circulatory and respiratory support in patients with cardiogenic shock. 4 Although potentially life-saving, ECMO is invasive, complex, resource intensive, and can be associated with serious complications. This Clinician Update will introduce ECMO technology, review indications and contraindications, discuss management, including maintaining and weaning support, and underscore potential complications.

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“…They were randomized 1:1 to conventional management without transfer vs transfer to one site and consideration of ECMO. A greater proportion of patients randomized to consideration of ECMO were alive at six months compared with patients randomized to conventional management (63% or 57/90 vs 50% or 45/90, respectively [7,200]). Despite conventional management, the authors concluded that it was appropriate to transfer adults with severe ARDS to a centre with an ECMO-based management protocol.…”

Section: Summary and Key Findingsmentioning

confidence: 99%

“…This is because of increased cost and logistics but also because of disappointing results from the two previous randomized trials. 4,5 There has been renewed interest in adult ECMO due to encouraging results from case series, 6,7 improved ECMO technology, 2 general advances in critical care, 3,8 and, most recently, the use of ECMO in H1N1 patients. 9,10 In fact, CESAR was published electronically in the same month period as a retrospective case review of ECMO in adult respiratory failure 11 and a meta-analysis of ECMO following adult cardiac arrest.…”

Section: Critical Appraisalmentioning

confidence: 99%

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Extracorporeal membrane oxygenation (ECMO) in severe adult respiratory distress syndrome

Brindley

Cave

Lequier

2010

Can J Anesth/J Can Anesth

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Article assessedPeek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009; 374: 1351-63. Critical care issueSevere adult respiratory distress syndrome (ARDS) remains associated with high mortality despite improved ventilatory techniques. While extracorporeal membrane oxygenation (ECMO) is not uncommon in neonatal/pediatric critical care, studies had yet to show similar benefits in adults. Therefore, the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) Trial by Peek et al. 1 was eagerly anticipated. It was the first randomized study of ECMO in adult patients in over 15 yr and the largest ever concerning this condition. 2 Summary and key findingsIn this multicentre randomized control trial from the United Kingdom, 180 patients, aged 18-65 yr, were analyzed. The patients had severe but potentially reversible respiratory failure, a Murray Score of C 3.0 (determined by combining PaO 2 /F I 0 2 ratio, positive end expiratory pressure level, lung compliance, chest radiograph appearance, and F I 0 2 of 1.0), or uncompensated hypercapnea (pH \ 7.2) despite conventional treatment. They were randomized 1:1 to conventional management without transfer vs transfer to one site and consideration of ECMO. A greater proportion of patients randomized to consideration of ECMO were alive at six months compared with patients randomized to conventional management (63% or 57/90 vs 50% or 45/90, respectively). This outcome did not reach statistical significance (relative risk 0.73; 95% confidence interval [CI] [0.52-1.03]; P = 0.07). However, a significantly greater percentage of patients randomized to consideration of ECMO survived to six months without severe disability compared with patients randomized to conventional management (63% [57/90] vs 47% [41/87], respectively; relative risk 0.69; 95% CI [0.05-0.97]; P = 0.03). Referral for ECMO consideration was associated with 0.03 quality-adjusted years (QALYS) at six months. The cost per QALY for ECMO was 19,252 pounds sterling (GBP) (95% CI [7,200]). Despite conventional management, the authors concluded that it was appropriate to transfer adults with severe ARDS to a centre with an ECMO-based management protocol. Critical appraisalCurrent state of the literature and study relevance Extra corporeal membrane oxygenation is accepted as a standard-of-care for neonates and children with progressive respiratory and/or cardiac failure refractory to conventional management. [1][2][3] In contrast, adult ECMO is currently confined to a few specialized centres and reserved for exceptional cases. This is because of increased cost and logistics but also because of disappointing results from the two previous randomized trials. 4,5

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Extracorporeal Membrane Oxygenation for Adult Respiratory Failure

Cited by 230 publications

References 14 publications

Extracorporeal Life Support for Acute Respiratory Failure. A Systematic Review and Metaanalysis

Extracorporeal Life Support for Acute Respiratory Failure. A Systematic Review and Metaanalysis

Extracorporeal Membrane Oxygenation in Adults With Cardiogenic Shock

Extracorporeal membrane oxygenation (ECMO) in severe adult respiratory distress syndrome

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