Ventilatory management of patients on ECMO

Abstract

Extracorporeal membrane oxygenation (ECMO) is the final treatment offered to patients of acute respiratory distress syndrome (ARDS). The survival (to discharge) of patients on veno-venous ECMO is approximately 59% with an average duration of 8 days. The ventilatory management of lungs during the ECMO may have an impact on mortality. An ideal ventilation modality should promote recovery, prevent further damage to the alveoli, and enable weaning from mechanical ventilation. This article reviews the concept of "baby lung" in ARDS and the current evidence for the use of lung protective ventilation, prevention of ventilator-induced lung injury, recommended modes of mechanical ventilation, ideal ventilatory parameters (tidal volume, positive end expiratory pressure, plateau pressure, respiratory rate, fractional inspired oxygen concentration), and use of adjuncts (prone positioning, neuromuscular blocking agents) during the ECMO course.

Early veno-venous extracorporeal membrane oxygenation is an effective strategy for traumatically injured patients presenting with refractory respiratory failure

“…After excluding nontrauma VV ECMO patients, all patients who were admitted to the trauma service and were subsequently placed on VV ECMO from January 1, 2014, to August 30, 2022, were screened for inclusion in our study. Early VV was defined as 1 : admission with a trauma diagnosis, 2 VV ECMO without alternate ECMO cannulation strategy (veno-arterial or veno-venoartial), 3 cannulation within the first 48 hours of admission, and 4 procedural or surgical intervention related to a traumatic injury after cannulation and while still on VV ECMO.…”

“…Veno-venous extracorporeal membrane oxygenation (VV ECMO) is used for patients with respiratory failure and acute respiratory distress syndrome (ARDS) who have failed conventional ventilator management 1 . While VV ECMO does not address the underlying pulmonary pathology, the treatment provides two essential benefits 1 : allows for lower tidal volume ventilation or “lung rest” to prevent secondary injury and 2 rapidly corrects refractory hypoxemia and respiratory acidosis through dissolved carbon dioxide removal 2,3 . Patients unstable from the hemodynamic effects of profound hypoxia and hypercarbia can be stabilized on VV ECMO, and ventilator modes and settings with a high risk of volutrauma and barotrauma are minimized 4,5 …”

“…1 While VV ECMO does not address the underlying pulmonary pathology, the treatment provides two essential benefits 1 : allows for lower tidal volume ventilation or "lung rest" to prevent secondary injury and 2 rapidly corrects refractory hypoxemia and respiratory acidosis through dissolved carbon dioxide removal. 2,3 Patients unstable from the hemodynamic effects of profound hypoxia and hypercarbia can be stabilized on VV ECMO, and ventilator modes and settings with a high risk of volutrauma and barotrauma are minimized. 4,5 Traditionally, VV ECMO has been primarily used for medical causes of ARDS, with notably increased use during the H1N1 and COVID-19 pandemics.…”

Decreased PRESET-Score corresponds with improved survival in COVID-19 veno-venous extracorporeal membrane oxygenation

“…1 VV ECMO improves outcomes in patients with ARDS 2 likely by facilitating improved gas exchange and thus allowing the delivery of lung protective ventilation and minimization of secondary lung injury. 3 Over the past 20 years, improvements in ECMO technology have made it more available to patients globally. 4 As the use of VV ECMO has become more prevalent, so has the use of scoring systems to help identify which patients may most benefit from its use.…”

Microstructured Hollow Fiber Membranes: Potential Fiber Shapes for Extracorporeal Membrane Oxygenators

“…The use of respiratory assistance devices for patients with severe forms of respiratory failure, such as extracorporeal membrane oxygenators, allow for low tidal volume protective ventilation, therefore reducing the stress associated with mechanical ventilation [1]. Improving the efficiency of hollow fiber membrane oxygenators is a crucial topic as the survival rate for patients is low (between 60 and 70% [2]), which is partially contributed to by the large amount of blood that is circulated out of the body and into the membrane module [3]. Therefore, a potential way to optimize oxygenator performance is to increase the membrane area available for CO 2 and O 2 gas exchange, without increasing the priming volume of the device.…”