Extracorporeal membrane oxygenation support in adult patients with acute respiratory distress syndrome

ABSTRACT

Introduction: The global number of patients receiving extracorporeal membrane oxygenation (ECMO) support has been growing after several studies highlighted the favorable results attained in cases of severe respiratory failure. However, evidence-based guidelines for optimal use of ECMO are lacking.

Areas covered: This review covers optimal candidates, timing of initiation, strategies for patient management including mechanical ventilation, and decision-making regarding discontinuation of ECMO based on its potential role in treatment of patients with acute respiratory distress syndrome.

Expert opinion: Early initiation of ECMO should be considered if hypoxemia and uncompensated hypercapnia do not respond to optimal conventional treatment. Use of a comprehensive management approach for preventing additional lung injury and extrapulmonary organ failure is critical during ECMO support to ensure the best outcome. The possibility of weaning from ECMO should be fully assessed by a multidisciplinary team during ECMO support. Futility should not be determined solely by duration of ECMO, and use of prolonged ECMO for lung recovery may be worthwhile.

KEYWORDS:

• Extracorporeal membrane oxygenation
• extracorporeal life support
• acute respiratory distress syndrome
• case management

Article Highlights

• Recently, the EOLIA trial has shown significantly lower treatment failure rates in patients who received an early initiation of ECMO compared with patients using ECMO as rescue therapy. Although the survival benefit has not yet been identified, in high-risk patients in whom treatment failure can be fatal, ECMO could be considered early in the course of severe ARDS rather than as a late rescue treatment.

• The optimal strategies for mechanical ventilation during ECMO have not yet been defined; however, it is typically accepted that the use of ultraprotective lung ventilation (combining low tidal volumes and limited inspiratory pressures) is beneficial for minimizing ventilator-induced lung injury.

• Adoption of a comprehensive management approach for preventing additional lung injury and extrapulmonary organ failure is critical while receiving ECMO support to ensure the best outcome.

• The time to lung function recovery varies by patient. Prolonged ECMO support is not a predictor for poor prognosis if there is a possibility of lung recovery.

• RV dysfunction is common in ARDS. Regular cardiac function monitoring and RV protective strategies are necessary. If RV failure occurs, modification of ECMO configuration can be considered to unload the right heart and maintain hemodynamic stability.

• To provide the highest quality of treatment and yield the best outcomes, all ECMO centers should establish a multidisciplinary ECMO team.

Declaration of Interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This work was supported by the Samsung Medical Center grant [OTA1802901].