Extracorporeal membrane oxygenation

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Extracorporeal membrane oxygenation
Veno-arterial (VA) ECMO for cardiac or respiratory failure.jpg
Other namesExtracorporeal life support (ECLS)
ICD-10-PCS 5A15223
ICD-9-CM 39.65
MeSH 29295
MedlinePlus 007234
HCPCS-L2 36822

Extracorporeal membrane oxygenation (ECMO), is a form of extracorporeal life support, providing prolonged cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of oxygen, gas exchange or blood supply (perfusion) to sustain life. The technology for ECMO is largely derived from cardiopulmonary bypass, which provides shorter-term support with arrested native circulation. The device used is a membrane oxygenator, also known as an artificial lung.

Contents

ECMO works by temporarily drawing blood from the body to allow artificial oxygenation of the red blood cells and removal of carbon dioxide. Generally, it is used either post-cardiopulmonary bypass or in late-stage treatment of a person with profound heart and/or lung failure, although it is now seeing use as a treatment for cardiac arrest in certain centers, allowing treatment of the underlying cause of arrest while circulation and oxygenation are supported. ECMO is also used to support patients with the acute viral pneumonia associated with COVID-19 in cases where artificial ventilation alone is not sufficient to sustain blood oxygenation levels.

Medical uses

ECMO sketch Ecmo schema-1-.jpg
ECMO sketch
ECMO circuit ECMO in H1N1 patient in Santa Cruz Hospital - Lisbon.jpg
ECMO circuit
A MAQUET hollow fiber membrane oxygenator Oksigenator QUADROX kompanii MAQUET.jpg
A MAQUET hollow fiber membrane oxygenator

Guidelines that describe the indications and practice of ECMO are published by the Extracorporeal Life Support Organization (ELSO). Criteria for the initiation of ECMO vary by institution, but generally include acute severe cardiac or pulmonary failure that is potentially reversible and unresponsive to conventional management. Examples of clinical situations that may prompt the initiation of ECMO include the following: [1]

In those with cardiac arrest or cardiogenic shock, it is believed to improve survival and good outcomes. [4] However, a recent clinical trial has shown that in patients with cardiogenic shock following acute myocardial infarction, ECLS did not improve survival (as measured via 30-day mortality); on the contrary, it resulted in increased complications (e.g., major bleeding, lower limb ischemia). [5] This finding is corroborated by a recent meta-analysis [6] that used data from four previous clinical trials, indicating a need to reassess current guidelines for initiation of ECLS treatment.

Use in COVID-19 patients

Beginning in early February 2020, doctors in China increasingly used ECMO as an adjunct support for patients presenting with acute viral pneumonia associated with SARS-CoV-2 infection (COVID-19) when, with ventilation alone, the blood oxygenation levels still remain too low to sustain the patient. [7] Initial reports indicated that it assisted in restoring patients' blood oxygen saturation and reducing fatalities among the approximately 3% of severe cases where it was utilized. [8] For critically ill patients, the mortality rate reduced from around 59–71% with conventional therapy to approximately 46% with extracorporeal membrane oxygenation. [9] A March 2021 Los Angeles Times cover story illustrated the efficacy of ECMO in an extremely challenging COVID patient. [10] In February 2021, three pregnant Israeli women who had "very serious" cases of COVID-19 were given ECMO treatment and it seemed this treatment option would continue. [11]

Outcomes

Early studies had shown survival benefit with use of ECMO for people in acute respiratory failure especially in the setting of acute respiratory distress syndrome. [12] [13] A registry maintained by ELSO of nearly 51,000 people that have received ECMO has reported outcomes with 75% survival for neonatal respiratory failure, 56% survival for pediatric respiratory failure, and 55% survival for adult respiratory failure. [14] Other observational and uncontrolled clinical trials have reported survival rates from 50 to 70%. [15] [16] These reported survival rates are better than historical survival rates. [17] [18] [19] Even though ECMO is used for a range of conditions with varying mortality rates, early detection is key to prevent the progression of deterioration and increase survival outcomes. [20]

In the United Kingdom, veno-venous ECMO deployment is concentrated in designated ECMO centers to potentially improve care and promote better outcomes.

Contraindications

Most contraindications are relative, balancing the risks of the procedure versus the potential benefits. The relative contraindications are:

Side effects and complications

Neurologic

A common consequence in ECMO-treated adults is neurological injury, which may include intracerebral hemorrhage, subarachnoid hemorrhage, ischemic infarctions in susceptible areas of the brain, hypoxic-ischemic encephalopathy, unexplained coma, and brain death. [21] Bleeding occurs in 30 to 40% of those receiving ECMO and can be life-threatening. It is due to both the necessary continuous heparin infusion and platelet dysfunction. Meticulous surgical technique, maintaining platelet counts greater than 100,000/mm3, and maintaining the target activated clotting time reduce the likelihood of bleeding.[ citation needed ]

Blood

Heparin-induced thrombocytopenia (HIT) is increasingly common among people receiving ECMO. When HIT is suspected, the heparin infusion is usually replaced by a non-heparin anticoagulant. [22]

There is retrograde blood flow in the descending aorta whenever the femoral artery and vein are used for VA (Veno-Arterial) ECMO. Stasis of the blood can occur if left ventricular output is not maintained, which may result in thrombosis.[ citation needed ]

Bridge-to-assist device

In VA ECMO, those whose cardiac function does not recover sufficiently to be weaned from ECMO may be bridged to a ventricular assist device (VAD) or transplant. A variety of complications can occur during cannulation, including vessel perforation with bleeding, arterial dissection, distal ischemia, and incorrect location.[ citation needed ]

Children

Preterm infants, having inefficiency of the heart and lungs, are at unacceptably high risk for intraventricular hemorrhage (IVH) if ECMO is performed at a gestational age less than 32 weeks. [23]

Infections

The prevalence of hospital-acquired infections during ECMO is 10-12% (higher compared to other critically ill patients). Coagulase-negative staphylococci, Candida spp., Enterobacteriaceae and Pseudomonas aeruginosa are the most frequently involved pathogens. ECMO patients display a high incidence of ventilator-associated pneumonia (24.4 cases/1000 ECMO days), with a major role played by Enterobacteriaceae. The infectious risk was shown to increase along the duration of the ECMO run, which is the most important risk factor for the development of infections. Other ECMO-specific factors predisposing to infections include the severity of illness in ECMO patients, the high risk of bacterial translocation from the gut and ECMO-related impairment of the immune system. Another important issue is the microbial colonisation of catheters, ECMO cannulae and the oxygenator. [24]

Types

Veno-arterial (VA) ECMO for cardiac or respiratory failure. Veno-arterial (VA) ECMO for cardiac or respiratory failure.jpg
Veno-arterial (VA) ECMO for cardiac or respiratory failure.
Veno-venous (VV) ECMO for respiratory failure. Veno-venous (VV) ECMO for isolated respiratory failure.jpg
Veno-venous (VV) ECMO for respiratory failure.

There are several forms of ECMO; the two most common are veno-arterial (VA) ECMO and veno-venous (VV) ECMO. In both modalities, blood drained from the venous system is oxygenated outside of the body. In VA ECMO, this blood is returned to the arterial system and in VV ECMO the blood is returned to the venous system. In VV ECMO, no cardiac support is provided.

Veno-arterial

In veno-arterial (VA) ECMO, a venous cannula is usually placed in the right or left common femoral vein for extraction, and an arterial cannula is usually placed into the right or left femoral artery for infusion. [26] The tip of the femoral venous cannula should be maintained near the junction of the inferior vena cava and right atrium, while the tip of the femoral arterial cannula is maintained in the iliac artery. [26] In adults, accessing the femoral artery is preferred because the insertion is simpler. [26] Central VA ECMO may be used if cardiopulmonary bypass has already been established or emergency re-sternotomy has been performed (with cannulae in the right atrium (or SVC/IVC for tricuspid repair) and ascending aorta).

VA ECMO is typically reserved when native cardiac function is minimal to mitigate increased cardiac stroke work associated with pumping against retrograde flow delivered by the aortic cannula.

Veno-venous

In veno-venous (VV) ECMO, cannulae are usually placed in the right common femoral vein for drainage and right internal jugular vein for infusion. [27] Alternatively, a dual-lumen catheter is inserted into the right internal jugular vein, draining blood from the superior and inferior vena cavae and returning it to the right atrium.

Initiation

ECMO should be performed only by clinicians with training and experience in its initiation, maintenance, and discontinuation. ECMO insertion is typically performed in the operating room setting by a cardiothoracic surgeon. ECMO management is commonly performed by a registered nurse, respiratory therapist, or a perfusionist. Once it has been decided to inititiate ECMO, the patient is anticoagulated with intravenous heparin to prevent thrombus formation from clotting off the oxygenator. Prior to initiation, an IV bolus of heparin is given and measured to ensure that the activated clotting time (ACT) is between 300 and 350 seconds. Once the ACT is between this range, ECMO can be initiated and a heparin drip will be started after as a maintenance dose. [20] : 143 

Cannulation

Cannulae can be placed percutaneously by the Seldinger technique, a relatively straightforward and common method for obtaining access to blood vessels, or via surgical cutdown. The largest cannulae that can be placed in the vessels are used in order to maximize flow and minimize shear stress. However, limb ischemia is one of the notorious complications of ECMO but can be avoided utilizing a proper distal limb perfusion method. [28] In addition, ECMO can be used intraoperatively during lung transplantation to stabilize the patient with excellent outcomes. [29] [30]

ECMO required for complications post-cardiac surgery can be placed directly into the appropriate chambers of the heart or great vessels. Peripheral (femoral or jugular) cannulation can allow patients awaiting lung transplantation to remain awake and ambulatory with improved post-transplant outcomes. [31] [32]

Titration

Following cannulation and connection to the ECMO circuit, the appropriate amount of blood flow through the ECMO circuit is determined using hemodynamic parameters and physical exam. Goals of maintaining end-organ perfusion via ECMO circuit are balanced with sufficient physiologic blood flow through the heart to prevent stasis and subsequent formation of blood clot.

Maintenance

A respiratory therapist takes a blood sample from a newborn in preparation for ECMO therapy. A Resperatory Therapist treating a newborn child Pulaski County Technical College Respiratory Therapist Program.jpg
A respiratory therapist takes a blood sample from a newborn in preparation for ECMO therapy.

Once the initial respiratory and hemodynamic goals have been achieved, the blood flow is maintained at that rate. Frequent assessment and adjustments are facilitated by continuous venous oximetry, which directly measures the oxyhemoglobin saturation of the blood in the venous limb of the ECMO circuit.

Special considerations

VV ECMO is typically used for respiratory failure, while VA ECMO is used for cardiac failure. There are unique considerations for each type of ECMO, which influence management.

Blood flow

High flow rates are usually desired during VV ECMO to optimize oxygen delivery. In contrast, the flow rate used during VA ECMO must be high enough to provide adequate perfusion pressure and venous oxyhemoglobin saturation (measured on drainage blood) but low enough to provide sufficient preload to maintain left ventricular output.

Diuresis

Since most people are fluid-overloaded when ECMO is initiated, aggressive diuresis is warranted once the patient is stable on ECMO. Ultrafiltration can be easily added to the ECMO circuit if the patient has inadequate urine output. ECMO "chatter", or instability of ECMO waveforms, represents under-resuscitation and would support cessation of aggressive diuresis or ultrafiltration. There is an increased risk of acute kidney injury related to the use of ECMO and systemic inflammatory response. [33]

Left ventricular monitoring

Left ventricular output is rigorously monitored during VA ECMO because left ventricular function can be impaired from increased afterload, which can in turn lead to formation of thrombus within the heart. [34] [35]

Weaning and discontinuing

For those with respiratory failure, improvements in radiographic appearance, pulmonary compliance, and arterial oxyhemoglobin saturation indicate that the person may be ready to be taken off ECMO support. For those with cardiac failure, enhanced aortic pulsatility correlates with improved left ventricular output and indicates that they may be ready to be taken off ECMO support. If all markers are in good status, the blood flows on the ECMO will be slowly decreased and the patients parameters will be observed during this time to ensure that the patient can tolerate the changes. When the flows are below 2 liters per minute, permanent removal is attempted and the patient is continuously monitored during this time until the cannulae can be removed. [20] : 149 

Veno-venous ECMO liberation trial

VV ECMO trials are performed by eliminating all countercurrent sweep gas through the oxygenator. Extracorporeal blood flow remains constant, but gas transfer does not occur. They are then observed for several hours, during which the ventilator settings that are necessary to maintain adequate oxygenation and ventilation off ECMO are determined as indicated by arterial and venous blood gas results.

Veno-arterial ECMO liberation trial

VA ECMO trials require temporary clamping of both the drainage and infusion lines, while allowing the ECMO circuit to circulate through a bridge between the arterial and venous limbs. This prevents thrombosis of stagnant blood within the ECMO circuit. In addition, the arterial and venous lines should be flushed continuously with heparinized saline or intermittently with heparinized blood from the circuit. In general, VA ECMO trials are shorter in duration than VV ECMO trials because of the higher risk of thrombus formation.

History

ECMO was developed in the 1950s by John Gibbon, and then by C. Walton Lillehei. The first use for neonates was in 1965. [36] [37]

Banning Gray Lary [38] first demonstrated that intravenous oxygen could maintain life. His results were published in Surgical Forum in November 1951. [39] Lary commented on his initial work in a 2007 presentation wherein he writes, "Our research began by assembling an apparatus that, for the first time, kept animals alive while breathing pure nitrogen. This was accomplished with very small bubbles of oxygen injected into the blood stream. These bubbles were made by adding a 'wetting agent' to oxygen being forced through a porcelain filter into the venous blood stream. Shortly after its initial presentation to the American College of Surgeons, this apparatus was reviewed by Walton Lillehei who with DeWall made the first practical heart[–]lung machine that employed a bubble oxygenator. With variations such machines were used for the next twenty years."

Manufacturers

Availability by country

Country/territoryContinentHospitals equippedUnits
United StatesNorth America361 (in 2022) [41]
CanadaNorth America23 (in 2022) [41]
AustraliaOceania146 (in 2020) [42]
BrazilSouth America21 (in 2021) [43]
England and WalesEurope5 (in 2020) [44] 15 (in 2020) [44]
Northern IrelandEurope0 (in 2020) [45] 0 (in 2020) [45]
ScotlandEurope1 (in 2020) [45] 6 (in 2020) [45]
IrelandEurope1 (in 2024)2 (in 2024) [46]
GermanyEurope214 (in 2020) [47] 779 (in 2021) [48]
PolandEurope47 (in 2020) [49]
SwedenEurope7 or more (in 2020) [50]
AlbaniaEurope0 (in 2020) [51] 0 (in 2020) [51]
RussiaEurope124 + 17 (in 2020) [52]
MoscowEurope16 (in 2020) [53]
Saint Petersburg, RussiaEurope719 (in 2020) [54]
JapanAsia2208 (in 2020) [55]
Mainland ChinaAsia400 (approx. in 2020) [56]

2,857 (in 2023) [57]

South KoreaAsia350 (in 2023)
TaiwanAsia51 (in 2016) [58] 105 (in 2016) [58]

129 (including rental units, in 2016) [59]

Sri Lanka South Asia2 (in 2021) [60] 2 (in 2021) [60]

Research

Randomized controlled trials (RCTs)

Four randomized controlled trials (RCTs) have been conducted to evaluate the effectiveness of ECMO in respiratory failure patients. Early trials conducted by Zapol et al. [61] and Morris et al. [62] were plagued by technical challenges related to the ECMO technology available in the 1970s and 1990s. The CESAR [63] and EOLIA [64] trials utilized modern ECMO systems and are considered the central ECMO RCTs.

CESAR Trial (2009)

The Conventional Ventilatory Support vs. Extracorporeal Membrane Oxygenation for Severe Adult Respiratory Failure (CESAR) Trial was a UK-based multicenter RCT aiming to evaluate the safety, efficacy and cost effectiveness of ECMO compared to conventional mechanical ventilation in adults with severe but reversible respiratory failure. [63] Death or severe disability at 6 months or prior to hospital discharge was the primary outcome. The primary outcome was analyzed by intention to treat only. Economic analysis included quality-adjusted life-years (QALYs), analysis of cost generating events, cost-utility 6-months post-randomization and modelling of life-time cost utility. The trial planned to enroll 180 patients; 90 to each arm.

The Trial met its enrollment goal of 180 patients. 68 of the 90 (75%) of the patients intended to be treated with ECMO were actually treated with ECMO. Survival of patients allocated to the ECMO group (i.e. referred for consideration for treatment with ECMO) was significantly higher than patients allocated to the conventional ventilation group (63% vs 47%, p=0.03). The referral to ECMO group gained 0.03 QALY compared to the conventional ventilation group at the 6-month follow-up. The referral to ECMO group had longer lengths of stay and higher costs. [63]

No standardized treatment protocol for the conventional ventilation group is the main limitation of the CESAR study. [63] [65] The trial authors note that this occurred due to the inability of enrolling sites to agree on a protocol. [63] This resulted in control patients not receiving lung protective ventilation [63] [66] which is known to improve mortality in ARDS patients. [67]

The authors conclude that referral of patients with severe, potentially reversible respiratory failure to an ECMO center can significantly improve 6-month, severe disability free survival. [63] The CESAR trial results do provide a direct survival comparison for treatment with ECMO versus conventional mechanical ventilation alone since only 75% of the ECMO group were actually treated with ECMO. [66]

EOLIA Trial (2018)

The ECMO to Rescue Lung Injury in Severe ARDS (EOLIA) Trial [64] was designed to evaluate the effects of early ECMO initiation compared to continued standard of care (conventional mechanical ventilation) in severe ARDS patients. Mortality at 60 days was the primary endpoint. The calculated sample size was 331 patients with an intent to show a 20% reduction in absolute mortality in the ECMO group. The main secondary endpoint was treatment failure – cross-over to ECMO due to refractory hypoxemia or death in the control group and death in the ECMO group.

Following the fourth planned interim analysis the trial was ended due to futility. A total of 249 patients were enrolled at study termination. Thirty-five control group patients (28%) required emergency cross-over to ECMO. Results of EOLIA demonstrated no significant difference in 60-day mortality between the ECMO group and the control group (35% vs 46%, respectively). [64] The interpretation of this result however is complicated by the cross-over patients. [68] The secondary endpoint, treatment failure, demonstrated a relative risk of 0.62 (p<0.001) in favor of the ECMO group. Results of the secondary endpoint should be interpreted cautiously due to the primary end point results. With respect to safety, the ECMO group had significantly higher rates of severe thrombocytopenia and bleeding requiring transfusion, but lower rates of ischemic stroke. [64]

The primary limitation to the EOLIA Trial was that it was underpowered. For EOLIA to have been properly powered to detect significance of an 11% reduction in mortality a total of 624 patients would need to have been enrolled. Such a trial would take 9 years based on the EOLIA recruitment rates and is likely not feasible. [65]

The main conclusion the study authors drew from these results is that early ECMO initiation in severe ARDS patients does not provide a mortality benefit compared to continued standard of care treatment. [64] Subsequent editorials by key opinion leaders suggest that the practical implication is that ECMO may improve mortality if used as a rescue therapy for patients failing conventional ARDS therapies. [68] [69]

Related Research Articles

<span class="mw-page-title-main">Respiratory failure</span> Inadequate gas exchange by the respiratory system

Respiratory failure results from inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels. A drop in the oxygen carried in the blood is known as hypoxemia; a rise in arterial carbon dioxide levels is called hypercapnia. Respiratory failure is classified as either Type 1 or Type 2, based on whether there is a high carbon dioxide level, and can be acute or chronic. In clinical trials, the definition of respiratory failure usually includes increased respiratory rate, abnormal blood gases, and evidence of increased work of breathing. Respiratory failure causes an altered state of consciousness due to ischemia in the brain.

<span class="mw-page-title-main">Cardiopulmonary bypass</span> Technique that temporarily takes over the function of the heart and lungs during surgery

Cardiopulmonary bypass (CPB) or heart-lung machine also called the pump or CPB pump is a machine that temporarily takes over the function of the heart and lungs during open-heart surgery by maintaining the circulation of blood and oxygen throughout the body. As such it is an extracorporeal device.

<span class="mw-page-title-main">Mechanical ventilation</span> Method to mechanically assist or replace spontaneous breathing

Mechanical ventilation or assisted ventilation is the medical term for using a ventilator machine to fully or partially provide artificial ventilation. Mechanical ventilation helps move air into and out of the lungs, with the main goal of helping the delivery of oxygen and removal of carbon dioxide. Mechanical ventilation is used for many reasons, including to protect the airway due to mechanical or neurologic cause, to ensure adequate oxygenation, or to remove excess carbon dioxide from the lungs. Various healthcare providers are involved with the use of mechanical ventilation and people who require ventilators are typically monitored in an intensive care unit.

<span class="mw-page-title-main">Intensive care medicine</span> Medical care subspecialty, treating critically ill

Intensive care medicine, also called critical care medicine, is a medical specialty that deals with seriously or critically ill patients who have, are at risk of, or are recovering from conditions that may be life-threatening. It includes providing life support, invasive monitoring techniques, resuscitation, and end-of-life care. Doctors in this specialty are often called intensive care physicians, critical care physicians, or intensivists.

<span class="mw-page-title-main">Cyanosis</span> Decreased oxygen in the blood

Cyanosis is the change of body tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen bound to the hemoglobin in the red blood cells of the capillary bed. Cyanosis is apparent usually in the body tissues covered with thin skin, including the mucous membranes, lips, nail beds, and ear lobes. Some medications may cause discoloration such as medications containing amiodarone or silver. Furthermore, mongolian spots, large birthmarks, and the consumption of food products with blue or purple dyes can also result in the bluish skin tissue discoloration and may be mistaken for cyanosis. Appropriate physical examination and history taking is a crucial part to diagnose cyanosis. Management of cyanosis involves treating the main cause, as cyanosis isn’t a disease, it is a symptom.

<span class="mw-page-title-main">Pulmonary edema</span> Fluid accumulation in the tissue and air spaces of the lungs

Pulmonary edema, also known as pulmonary congestion, is excessive fluid accumulation in the tissue or air spaces of the lungs. This leads to impaired gas exchange, most often leading to shortness of breath (dyspnea) which can progress to hypoxemia and respiratory failure. Pulmonary edema has multiple causes and is traditionally classified as cardiogenic or noncardiogenic.

<span class="mw-page-title-main">Acute respiratory distress syndrome</span> Respiratory failure due to widespread inflammation in the lungs

Acute respiratory distress syndrome (ARDS) is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. Symptoms include shortness of breath (dyspnea), rapid breathing (tachypnea), and bluish skin coloration (cyanosis). For those who survive, a decreased quality of life is common.

<span class="mw-page-title-main">Hypercapnia</span> Abnormally high tissue carbon dioxide levels

Hypercapnia (from the Greek hyper = "above" or "too much" and kapnos = "smoke"), also known as hypercarbia and CO2 retention, is a condition of abnormally elevated carbon dioxide (CO2) levels in the blood. Carbon dioxide is a gaseous product of the body's metabolism and is normally expelled through the lungs. Carbon dioxide may accumulate in any condition that causes hypoventilation, a reduction of alveolar ventilation (the clearance of air from the small sacs of the lung where gas exchange takes place) as well as resulting from inhalation of CO2. Inability of the lungs to clear carbon dioxide, or inhalation of elevated levels of CO2, leads to respiratory acidosis. Eventually the body compensates for the raised acidity by retaining alkali in the kidneys, a process known as "metabolic compensation".

<span class="mw-page-title-main">Cardiogenic shock</span> Shock due to heart dysfunction

Cardiogenic shock is a medical emergency resulting from inadequate blood flow to the body's organs due to the dysfunction of the heart. Signs of inadequate blood flow include low urine production, cool arms and legs, and decreased level of consciousness. People may also have a severely low blood pressure and heart rate.

<span class="mw-page-title-main">Hypoxemia</span> Abnormally low level of oxygen in the blood

Hypoxemia is an abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood. Hypoxemia has many causes, and often causes hypoxia as the blood is not supplying enough oxygen to the tissues of the body.

<span class="mw-page-title-main">Lung transplantation</span> Surgical procedure in which a patients diseased lungs are partially or totally replaced

Lung transplantation, or pulmonary transplantation, is a surgical procedure in which one or both lungs are replaced by lungs from a donor. Donor lungs can be retrieved from a living or deceased donor. A living donor can only donate one lung lobe. With some lung diseases, a recipient may only need to receive a single lung. With other lung diseases such as cystic fibrosis, it is imperative that a recipient receive two lungs. While lung transplants carry certain associated risks, they can also extend life expectancy and enhance the quality of life for those with end stage pulmonary disease.

Positive end-expiratory pressure (PEEP) is the pressure in the lungs above atmospheric pressure that exists at the end of expiration. The two types of PEEP are extrinsic PEEP and intrinsic PEEP. Pressure that is applied or increased during an inspiration is termed pressure support. PEEP is a therapeutic parameter set in the ventilator, or a complication of mechanical ventilation with air trapping (auto-PEEP).

<span class="mw-page-title-main">Fat embolism syndrome</span> Entry of fat into the bloodstream

Fat embolism syndrome occurs when fat enters the blood stream and results in symptoms. Symptoms generally begin within a day. This may include a petechial rash, decreased level of consciousness, and shortness of breath. Other symptoms may include fever and decreased urine output. The risk of death is about 10%.

<span class="mw-page-title-main">Diffuse alveolar damage</span> Non-fatal disease of the lungs

Diffuse alveolar damage (DAD) is a histologic term used to describe specific changes that occur to the structure of the lungs during injury or disease. Most often DAD is described in association with the early stages of acute respiratory distress syndrome (ARDS). It is important to note that DAD can be seen in situations other than ARDS and that ARDS can occur without DAD.

<span class="mw-page-title-main">Extracorporeal Life Support Organization</span>

The Extracorporeal Life Support Organization (ELSO) is a non profit organization established in 1989 supporting health care professionals and scientists who are involved in extracorporeal membrane oxygenation (ECMO). ELSO maintains a registry of both facilities and specialists trained to provide ECMO services. ELSO also maintains registry information that is used to support clinical research, support regulatory agencies, and support individual ELSO centers. ELSO provides educational programs for active centers as well as for facilities who may be involved in the transfer of patients to higher levels of care.

Prone ventilation, sometimes called prone positioning or proning, is a method of mechanical ventilation with the patient lying face-down (prone). It improves oxygenation in most patients with acute respiratory distress syndrome (ARDS) and reduces mortality. The earliest trial investigating the benefits of prone ventilation occurred in 1976. Since that time, many meta-analyses and one randomized control trial, the PROSEVA trial, have shown an increase in patients' survival with the more severe versions of ARDS. There are many proposed mechanisms, but they are not fully delineated. The proposed utility of prone ventilation is that this position will improve lung mechanics, improve oxygenation, and increase survival. Although improved oxygenation has been shown in multiple studies, this position change's survival benefit is not as clear. Similar to the slow adoption of low tidal volume ventilation utilized in ARDS, many believe that the investigation into the benefits of prone ventilation will likely be ongoing in the future.

Extracorporeal cardiopulmonary resuscitation is a method of cardiopulmonary resuscitation (CPR) that passes the patient's blood through a machine in a process to oxygenate the blood supply. A portable extracorporeal membrane oxygenation (ECMO) device is used as an adjunct to standard CPR. A patient who is deemed to be in cardiac arrest refractory to CPR has percutaneous catheters inserted into the femoral vein and artery. Theoretically, the application of ECPR allows for the return of cerebral perfusion in a more sustainable manner than with external compressions alone. By attaching an ECMO device to a person who has acutely undergone cardiovascular collapse, practitioners can maintain end-organ perfusion whilst assessing the potential reversal of causal pathology, with the goal of improving long-term survival and neurological outcomes.

Bridge therapy is therapy intended, in transportation metaphor, to serve as a figurative bridge to another stage of therapy or health, helping a patient past a challenging period caused by particular severe illness. There are various types of bridge therapy, such as bridge to transplant, bridge to candidacy, bridge to decision, bridge to recovery, and anticoagulation bridge. Bridge therapy exists in contrast to destination therapy, which is the figurative destination rather than a bridge to something else.

Extracorporeal life support (ECLS), is a set of extracorporeal modalities that can provide oxygenation, removal of carbon dioxide, and/or circulatory support, excluding cardiopulmonary bypass for cardiothoracic or vascular surgery.

The treatment and management of COVID-19 combines both supportive care, which includes treatment to relieve symptoms, fluid therapy, oxygen support as needed, and a growing list of approved medications. Highly effective vaccines have reduced mortality related to SARS-CoV-2; however, for those awaiting vaccination, as well as for the estimated millions of immunocompromised persons who are unlikely to respond robustly to vaccination, treatment remains important. Some people may experience persistent symptoms or disability after recovery from the infection, known as long COVID, but there is still limited information on the best management and rehabilitation for this condition.

References

  1. ↑ "General Guidelines for all ECLS Cases" (PDF). Extracorporeal Life Support Organization. Retrieved April 15, 2015.
  2. ↑ Amos S, Pollack R, Sarig I, Rudis E, Hirshoren N, Weinberger J, et al. (May 2023). "VA-ECMO for Thyroid Storm: Case Reports and Review of the Literature". The Israel Medical Association Journal: IMAJ. 25 (5): 349–350. ISSN   1565-1088. PMID   37245101.
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