Long- and short-term clinical impact of awake extracorporeal membrane oxygenation as bridging therapy for lung transplantation

Abstract

Background As lung transplantation (LTx) is becoming a standard treatment for end-stage lung disease, the use of bridging with extracorporeal membrane oxygenation (ECMO) is increasing. We examined the clinical impact of being awake during ECMO as bridging therapy in patients awaiting LTx. Methods In this single-center study, we retrospectively reviewed 241 consecutive LTx patients between October 2012 and March 2019; 64 patients received ECMO support while awaiting LTx. We divided into awake and non-awake groups and compared. Results Twenty-five patients (39.1%) were awake, and 39 (61.0%) were non-awake. The median age of awake patients was 59.0 (interquartile range, 52.5–63.0) years, and 80% of the group was men. The awake group had better post-operative outcomes than the non-awake group: statistically shorter post-operative intensive care unit length of stay [awake vs. non-awake, 6 (4–8.5) vs. 18 (11–36), p < 0.001], longer ventilator free days [awake vs. non-awake, 24 (17–26) vs. 0 (0–15), p < 0.001], and higher gait ability after LTx (awake vs. non-awake, 92% vs. 59%, p = 0.004), leading to higher 6-month and 1-year lung function (forced expiratory volume in 1 s: awake vs. non-awake, 6-month, 77.5% vs. 61%, p = 0.004, 1-year, 75% vs. 57%, p = 0.013). Furthermore, the awake group had significantly lower 6-month and 1-year mortality rates than the non-awake group (6-month 12% vs. 38.5%, p = 0.022, 1-year 24% vs. 53.8%, p = 0.018). Conclusions In patients with end-stage lung disease, considering the long-term and short-term impacts, the awake ECMO strategy could be useful compared with the non-awake ECMO strategy.

Extracorporeal Membrane Oxygenation Without Invasive Ventilation for Respiratory Failure in Adults: A Systematic Review*

“…A total of 57 articles including data from 467 awake ECMO patients (923 total ECMO patients) were included in the analysis ( Fig. 1 ) (21–73). Of these, 28 articles (49%) were case reports including a single patient each and 29 articles (51%) were case series with a median sample size of 10 patients (range, 3–65 patients) ( Supplementary Table 1 , http://links.lww.com/CCM/H411).…”

Awakening in extracorporeal membrane oxygenation as a bridge to lung transplantation

“…In 2019, Tipograf et al [ 11 ] adjusted the baseline characteristics using propensity score matching between the awake ECMO and non-bridged LTx groups and reported that there was no difference in post-LTx survival rate between 70 awake ECMO patients and non-bridged LTx patients (log-rank P=0.53). Furthermore, Kim et al recently reported that the awake ECMO group showed increased ventilator-free days, decreased intensive care unit (ICU) length of stay, and higher gait ability and lung function after LTx compared with the non-awake ECMO group [ 24 ].…”

“…A previous prospective study showed that lung function could be improved by adding inspiratory muscle training to the standard pulmonary rehabilitation [ 32 ]. In another retrospective study comparing lung function 6 months after LTx according to the spontaneous breathing status of patients using ECMO as a bridge to LTx, the spontaneous breathing group showed higher lung function than the non-awake group [ 24 ].…”

“…The use of sedatives has been associated with delirium, a condition that reduces interactions with healthcare providers [ 5 ]. During awake ECMO, patients with spontaneous breathing, reduced sedative dose, and no delirium can ingest orally and have less ICU psychosis [ 24 ]. Furthermore, patients can communicate with the medical staff and participate in decision-making.…”