Extracorporeal membrane oxygenation for severe influenza A (H1N1) acute respiratory distress syndrome: a prospective observational comparative study

Purpose

To compare characteristics, clinical evolution and outcome in adult patients with influenza A (H1N1) acute respiratory distress syndrome (ARDS) treated with or without extracorporeal membrane oxygenation (ECMO).

Methods

A prospective observational study of patients treated in Marseille South Hospital from October 2009 to January 2010 for confirmed influenza A (H1N1)-related ARDS. Clinical features, pulmonary dysfunction and mortality were compared between patients treated with and without ECMO.

Results

Of 18 patients admitted, 6 were treated with veno-venous and 3 with veno-arterial ECMO after median (interquartile, IQR) duration of mechanical ventilation of 10 (6–96) h. Six ECMO were initiated in a referral hospital by a mobile team, a median (IQR) of 3 (2–4) h after phone contact. Before ECMO, patients had severe respiratory failure with median (IQR) PaO₂ to FiO₂ ratio of 52 (50–60) mmHg and PaCO₂ of 85 (69–91) mmHg. Patients treated with or without ECMO had the same hospital mortality rate (56%, 5/9). Duration of ECMO therapy was 9 (4–14) days in survivors and 5 (2–25) days in non-survivors. Early improvement of PaO₂ to FiO₂ ratio was greater in ECMO survivors than non-survivors after ECMO initiation [295 (151–439) versus 131 (106–144) mmHg, p < 0.05]. Haemorrhagic complications occurred in four patients under ECMO, but none required surgical treatment.

Conclusions

ECMO may be an effective salvage treatment for patients with influenza A (H1N1)-related ARDS presenting rapid refractory respiratory failure, particularly when provided by a mobile team allowing early cannulation prior to transfer to a reference centre.     

Extracorporeal membrane oxygenation for severe ARDS in pregnant and postpartum women during the 2009 H1N1 pandemic

Purpose

To describe the technical challenges, efficacy, complications and maternal and infant outcomes associated with extracorporeal membrane oxygenation (ECMO) for severe adult respiratory distress syndrome (ARDS) in pregnant or postpartum patients during the 2009 H1N1 pandemic.

Methods

Twelve critically ill pregnant and postpartum women were included in this retrospective observational study on the application of ECMO for the treatment of severe ARDS refractory to standard treatment. The study was conducted at seven tertiary hospitals in Australia and New Zealand.

Results

Of the 12 patients treated with ECMO, 7 (58%) were pregnant and 5 (42%) were postpartum. Their median (interquartile range [IQR]) age was 29 (26?C33)?years, 6 (50%) were obese. Two patients were initially treated with veno-arterial (VA) ECMO. All others received veno-venous (VV) ECMO with one or two drainage cannulae. ECMO circuit-related complications were rare, circuit change was needed in only two cases and there was no sudden circuit failure. On the other hand, bleeding was common, leading to relatively large volumes of packed red blood cell transfusion (median [IQR] volume transfused was 3,499 [1,451?C4,874]?ml) and was the main cause of death (three cases). Eight (66%) patients survived to discharge and seven were ambulant, with normal oxygen saturations. The survival rate of infants whose mothers received ECMO was 71% and surviving infants were discharged home with no sequelae.

Conclusions

The use of ECMO for severe ARDS in pregnant and postpartum women was associated with a 66% survival rate. The most common cause of death was bleeding. Infants delivered of mothers who had received ECMO had a 71% survival rate and, like their mothers, had no permanent sequelae at hospital discharge.     

Extracorporeal support for trauma: A trauma quality improvement project (TQIP) analysis in patients with acute respiratory distress syndrome

IntroductionThe use of extracorporeal membrane oxygenation (ECMO) in trauma patients with severe acute respiratory distress syndrome (ARDS) continues to evolve. The objective of this study was to perform a comparative analysis of trauma patients with ARDS who received ECMO to a propensity matched cohort of patients who underwent conventional management.MethodsThe Trauma Quality Improvement Program (TQIP) database was queried from 2013 to 2016 for all patients with ARDS and those who received ECMO. Demographics, as well as clinical, injury, intervention, and outcome data were collected and analyzed. Patients with ARDS were divided into two groups, those who received ECMO and those who did not. A propensity score analysis was performed using the following criteria: age, gender, vital signs (HR, SBP) and GCS on admission, Injury Severity Score (ISS), and Abbreviated Injury Scale (AIS) score in several body regions. Outcomes between the groups were subsequently compared using univariate as well as Cox regression analyses.Secondary outcomes such as hospitalization (HLOS), ICU length-of-stay (LOS) and ventilation days stratified for patient demographics, timing of ECMO and anticoagulation status were compared.ResultsOver the 3-year study period, 8990 patients with ARDS were identified from the TQIP registry. Following exclusion, 3680 were included in the final analysis, of which 97 (2.6%) received ECMO. On univariate analysis following matching, patients who underwent ECMO had lower overall hospital mortality (23 vs 50%, p < 0.001) with higher rates of complications (p < 0.005), including longer HLOS. In those undergoing ECMO, early initiation (<7 days) was associated with shorter HLOS, ICU LOS, and fewer ventilator days. No difference was observed between the two groups with regard to anticoagulation.ConclusionExtracorporeal membrane oxygenation use in trauma patients with ARDS may be associated with improved survival, especially for young patients with thoracic injuries, early in the course of ARDS. Anticoagulation while on circuit was not associated with increased risk of hemorrhage or mortality, even in the setting of head injuries. The mortality benefit suggested with ECMO comes at the expense of a potential increase in complication rate and prolonged hospitalization.     

Neuropsychiatric outcome in subgroups of Intensive Care Unit survivors: Implications for after-care

PurposePoor neuropsychiatric outcomes are common in survivors of critical illness but it is unclear what patient groups to target for interventions to improve mental health. We compared anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms and health-related quality of life (HrQoL) across different subgroups of Intensive Care Unit (ICU) survivors.Materials and methodsA single-center cohort study was conducted in a mixed-ICU in the Netherlands among survivors of an ICU admission ≥48 h (n = 1730). Survivors received a survey one year after discharge, containing the Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale (IES/IES-R), and EQ-5D (response rate of 67%). Neuropsychiatric symptoms and quality of life were evaluated in a priori defined subgroups, by chi-square tests and Mann-Whitney U tests.ResultsSymptoms of anxiety (HADS anxiety ≥8), depression (HADS depression ≥8), and PTSD (IES ≥35; IES-R ≥ 1.6) were reported by 34%, 33%, and 19% of ICU survivors, with a median HrQoL utility score of 0.81 (IQR:0.65–1.00). These figures were similar for survivors of ARDS, sepsis, severe multiple organ failure (SOFA>11), or ICU stay ≥7 days.ConclusionsThis underlines the importance of prevention and treatment for neuropsychiatric symptoms in ICU survivors in general, not only in specific patient groups.     

Morphological changes in chest radiographs of patients with acute respiratory distress syndrome (ARDS)

Objective: To determine whether the quality of infiltrations in chest radiographs can accurately predict the histological extent of fibrotic change in patients with acute respiratory distress syndrome (ARDS). Design: Retrospective clinical investigation. Setting: Intensive care unit (ICU) of a university teaching hospital. Patients and methods: Of 47 patients treated with extracorporeal membrane oxygenation (ECMO) for severe ARDS over a 5-year period, 23 patients underwent open lung biopsy at thoracotomy for treatment, mostly of pneumothorax. Chest films obtained by portable chest roentgenography preceding the operation were reviewed retrospectively and compared to the histomorphological results of the lung specimen. Results: Chest radiographs displayed mixed alveolar-reticular opacification in 60.2 %, alveolar patterns in 22.9 % and reticular opacities in 10.5 %. In 0.4 % there were no infiltrates, 6 % could not be evaluated because of insufficient quality. There was no relevant difference between the right and left lungs. Subdividing patients into two groups according to the histological results of either absent or mild (1) or severe (2) lung fibrosis, we found an alveolar haziness in 12.3 % in group 1 compared with 28.2 % in group 2, while reticular characteristics were identified in 13 % and 11 %, respectively. Conclusions: The most common opacity in chest radiographs of patients with severe ARDS treated with ECMO is mixed alveolar-reticular opacification. Severe lung fibrosis is not positively correlated with a reticular radiographic pattern. ECMO does not lead to specific radiological changes in conventional radiograms, contrary to clinical findings that treatment with ECMO might induce pleural or pulmonic haemorrhage, especially in the earlier days when systemic heparinization had to be used instead of the heparin-coated tube-surfacing. Received: 24 November 1997 Accepted: 20 July 1998     

Characteristics and outcomes of patients treated with airway pressure release ventilation for acute respiratory distress syndrome: A retrospective observational study

BackgroundThe optimal mode of ventilation in acute respiratory distress syndrome (ARDS) remains uncertain. Airway pressure release ventilation (APRV) is a recognized treatment for mechanically-ventilated patients with severe hypoxaemia. However, contemporary data on its role as a rescue modality in ARDS is lacking. The goal of this study was to describe the clinical and physiological effects of APRV in patients with established ARDS.MethodsThis retrospective observational study was performed in a 23-bed adult intensive care unit in a tertiary extracorporeal membrane oxygenation (ECMO) referral centre. Patients with ARDS based on Berlin criteria were included through a prospectively-collected APRV database. Patients receiving APRV for less than six hours were excluded.ResultsFifty patients fulfilled the eligibility criteria. Prior to APRV initiation, median Murray Lung Injury Score was 3.5 (interquartile range (IQR) 2.5–3.9) and PaO₂/FiO₂ was 99 mmHg (IQR 73–137). PaO₂/FiO₂ significantly improved within twenty-four hours post-APRV initiation (ANOVA F(1, 27) = 24.34, P < .005). Two patients (4%) required intercostal catheter insertion for barotrauma. Only one patient (2%) required ECMO after APRV initiation, despite a majority (68%) fulfilling previously established criteria for ECMO at baseline. Hospital mortality rate was 38%.ConclusionsIn patients with ARDS-related refractory hypoxaemia treated with APRV, an early and sustained improvement in oxygenation, low incidence of clinically significant barotrauma and progression to ECMO was observed. The safety and efficacy of APRV requires further consideration.     

Outcome of acute respiratory distress syndrome patients treated with extracorporeal membrane oxygenation and brought to a referral center

Purpose

Patients with severe acute respiratory distress syndrome (ARDS) are candidates for extracorporeal membrane oxygenation (ECMO) therapy. The evaluation of organ severity is difficult in patients considered for cannulation in a distant hospital. This study was designed to identify early factors associated with hospital mortality in ARDS patients treated with ECMO and retrieved from referring hospitals.

Methods

Data from 85 consecutive ARDS patients equipped with ECMO by our mobile team and consequently admitted to our ICU were prospectively collected and analyzed.

Results

The main ARDS etiologies were community-acquired bacterial pneumonia (35 %), influenza pneumonia (23 %) (with 12 patients having been treated during the first half of the study period), and nosocomial pneumonia (14 %). The median (interquartile range) time between contact from the referring hospital and patient cannulation was 3 (1–4) h. ECMO was venovenous in 77 (91 %) patients. No complications occurred during transport by our mobile unit. Forty-eight patients died at the hospital (56 %). Based on a multivariate logistic regression, a score including age, SOFA score, and a diagnosis of influenza pneumonia was constructed. The probability of hospital mortality following ECMO initiation was 40 % in the 0–2 score class (n = 58) and 93 % in the 3–4 score class (n = 27). Patients with an influenza pneumonia diagnosis and a SOFA score before ECMO of less than 12 had a mortality rate of 22 %.

Conclusions

Age, SOFA score, and a diagnosis of influenza may be used to accurately evaluate the risk of death in ARDS patients considered for retrieval under ECMO from distant hospitals.     

Development of a practically usable prediction model for quality of life of ICU survivors: A sub-analysis of the MONITOR-IC prospective cohort study

PurposeAs the goal of ICU treatment is survival in good health, we aimed to develop a prediction model for ICU survivors' change in quality of life (QoL) one year after ICU admission.Materials & methodsThis is a sub-study of the prospective cohort MONITOR-IC study. Adults admitted ≥12 h to the ICU of a university hospital between July 2016–January 2019 were included. Moribund patients were excluded. Change in QoL one year after ICU admission was quantified using the EuroQol five-dimensional (EQ-5D-5L) questionnaire, and Short-Form 36 (SF-36). Multivariable linear regression analysis and best subsets regression analysis (SRA) were used. Models were internally validated by bootstrapping.ResultsThe PREdicting PAtients' long-term outcome for Recovery (PREPARE) model was developed (n = 1308 ICU survivors). The EQ-5D-models had better predictive performance than the SF-36-models. Explained variance (adjusted R²) of the best model (33 predictors) was 58.0%. SRA reduced the number of predictors to 5 (adjusted R² = 55.3%, SE = 0.3), including QoL, diagnosis of a Cardiovascular Incident and frailty before admission, sex, and ICU-admission following planned surgery.ConclusionsThough more long-term data are needed to ascertain model accuracy, in future, the PREPARE model may be used to better inform and prepare patients and their families for ICU recovery.     

External validation of scores proposed for estimation of survival probability of patients with severe adult respiratory distress syndrome undergoing extracorporeal membrane oxygenation therapy: a retrospective study

IntroductionThis study was designed as an external validation of the recently proposed Predicting Death for Severe ARDS on V-V ECMO (PRESERVE) score, The respiratory extracorporeal membrane oxygenation survival prediction (RESP) score and a scoring system developed for externally retrieved patients on extracorporeal membrane oxygenation (ECMO) at our institution. All scores are proposed for the estimation of survival probability after ECMO treatment for severe adult respiratory distress syndrome.MethodsData from 51 patients (2008 to 2013) were analyzed in this retrospective single-center study. A calculation of an adapted PRESERVE score, the RESP score as well as the score developed for externally retrieved ECMO patients was performed.ResultsSeventy one percent of patients received veno-venous (v-v) and 29% venous-arterial (v-a) ECMO support during the study period. Overall survival at 6 months was 55%, with a 61% survival rate for v-v cannulated patients and a 40% survival rate for v-a cannulated patients. The PRESERVE score discriminated survivors and non-survivors with an area under the curve of 0.67 (95% CI 0.52 to 0.82, P = 0.03). Analyzing survival prediction according to cannulation modus, the PRESERVE score and the RESP score significantly predicted survival for patients on v-v ECMO with an area under the curve of 0.75 (95% CI 0.57 to 0.92, P = 0.01) and 0.81 (95% CI 0.67 to 0.95, P = 0.035), respectively, while the scoring system developed for externally retrieved ECMO patients failed to predict survival in our study population. All scores failed to predict mortality for patients on v-a ECMO.ConclusionOur single-center validation confirms that the proposed PRESERVE and RESP score predict survival for patients treated with v-v ECMO for severe adult respiratory distress syndrome.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0875-z) contains supplementary material, which is available to authorized users.     

Early prediction of extracorporeal membrane oxygenation eligibility for severe acute respiratory distress syndrome in adults

PurposeAppropriately identifying and triaging patients with newly diagnosed acute respiratory distress syndrome (ARDS) who may progress to severe ARDS is a common clinical challenge without any existing tools for assistance.Materials and methodsUsing a retrospective cohort, a simple prediction score was developed to improve early identification of ARDS patients who were likely to progress to severe ARDS within 7 days. A broad array of comorbidities and physiologic variables were collected for the 12-hour period starting from intubation for ARDS. Extracorporeal membrane oxygenation (ECMO) eligibility was determined based on published criteria from recent ECMO guidelines and clinical trials. Separate data-driven and expert opinion approaches to prediction score creation were completed.ResultsThe study included 767 patients with moderate or severe ARDS who were admitted to the intensive care unit between January 1, 2005, and December 31, 2010. In the data-driven approach, incorporating the ARDS index (a novel variable incorporating oxygenation index and estimated dead space), aspiration, and change of Pao₂/fraction of inspired oxygen ratio into a simple prediction model yielded a c-statistic (area under the receiver operating characteristic curve) of 0.71 in the validation cohort. The expert opinion–based prediction score (including oxygenation index, change of Pao₂/fraction of inspired oxygen ratio, obesity, aspiration, and immunocompromised state) yielded a c-statistic of 0.61 in the validation cohort.ConclusionsThe data-driven early prediction ECMO eligibility for severe ARDS score uses commonly measured variables of ARDS patients within 12 hours of intubation and could be used to identify those patients who may merit early transfer to an ECMO-capable medical center.     

Assessment of electrical impedance tomography to set optimal positive end-expiratory pressure for veno-venous ECMO-treated severe ARDS patients

PurposeUltra-protective ventilation with low tidal volume is used in severe acute respiratory distress syndrome (ARDS) patients under extracorporeal membrane oxygenation (ECMO). However, the optimal positive end-expiratory pressure (PEEP) is unknown. The aim of our study was to assess electrical impedance tomography's (EIT) ability to choose the best PEEP for these patients.Materials and methodsA recruitment maneuver and after a decremental PEEP trial from 20 to 5 cmH₂0 were monitored by EIT, with lung images divided into four ventral-to-dorsal horizontal regions of interest. For each patient, three EIT-based PEEP were defined: PEEP ODCL_min (lowest pressure with the least EIT-based collapse lung [CL] and overdistension [OD]), PEEP ODCL₁₅ (lowest pressure able to limit EIT-based collapse to less than or equal to 15% with the least overdistension) and PEEP Comp (PEEP with the highest EIT-based compliance).ResultsHigh PEEP levels were significantly associated with more overdistension while decreasing PEEP led to more collapsed zones. PEEP ODCL₁₅ and PEEP Comp were in complete agreement with the reference Pulmonary PEEP (chosen according to usual respiratory clinical and ultrasound criteria), PEEP ODCLmin was in average agreement with the Pulmonary PEEP.ConclusionEIT may be a useful real-time monitoring technique to optimize the PEEP level in severe ARDS patients under ECMO.Take-home messageUltra-protective ventilation with low tidal volume is used in severe acute respiratory distress syndrome patients under extracorporeal membrane oxygenation (ECMO), but the optimal positive end-expiratory pressure is unknown. This trial shows that electrical impedance tomography may be an interesting non-invasive bedside tool to provide real-time monitoring of PEEP impact in severe ARDS patients under ECMO.The Pulmovista® electrical impedance tomography was provided by Dräger (Lübeck, Germany) during the study period. Dräger had no role in the study design, collection, analysis and interpretation of the data, writing the article, or the decision to submit the article for publication.     

A comparative analysis of the outcomes of patients with influenza or COVID-19 in a tertiary hospital in Belgium

IntroductionThe COVID-19 pandemic has emerged as a global health problem, associated with high morbidity and mortality rates. The aim of this study was to compare the outcomes of hospitalized patients with COVID-19 or with seasonal influenza in a teaching hospital in Belgium.MethodsIn this retrospective, single-center cohort study, 1384 patients with COVID-19 and 226 patients with influenza were matched using a propensity score with a ratio of 3:1. Primary outcomes included admission to intensive care unit (ICU), intubation rates, hospital length of stay, readmissions within 30 days and in-hospital mortality. Secondary outcomes included pulmonary bacterial superinfection, cardiovascular complications and ECMO.ResultsBased on the analysis of the matched sample, patients with influenza had an increased risk of readmission within 30 days (Risk Difference (RD): 0.07, 95% CI: 0.03 to 0.11) and admission to intensive care unit (RD: 0.09, 95% CI: 0.03 to 0.15) compared with those with COVID-19. Patients with influenza had also more pulmonary bacterial superinfections (46.2% vs 7.4%) and more cardiovascular complications (32% vs 3.9%) than patients with COVID-19.However, a two-fold increased risk of mortality (RD: ?0.10, 95% CI: 0.15 to ?0.05) was observed in COVID-19 compared to influenza. ECMO was also more required among the COVID-19 patients who died than among influenza patients (5% vs 0%).ConclusionsCOVID-19 is associated with a higher in-hospital mortality compared to influenza infection, despite a high rate of ICU admission in the influenza group. These findings highlighted that the severity of hospitalized patients with influenza should not be underestimated.     

Long-term quality of life in patients with acute respiratory distress syndrome requiring extracorporeal membrane oxygenation for refractory hypoxaemia

Introduction

The purpose of the study was to assess the long term outcome and quality of life of patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) for refractory hypoxemia.

Methods

A retrospective observational study with prospective health related quality of life (HRQoL) assessment was conducted in ARDS patients who had ECMO as a rescue therapy for reversible refractory hypoxemia from January 2009 until April 2011 in a tertiary Australian centre. Survival and long-term quality of life assessment, using the Short-Form 36 (SF-36) and the EuroQol health related quality of life questionnaire (EQ5D) were assessed and compared to international data from other research groups.

Results

Twenty-one patients (mean age 36.3 years) with ARDS receiving ECMO for refractory hypoxemia were studied. Eighteen (86%) patients were retrieved from external intensive care units (ICUs) by a dedicated ECMO retrieval team. Eleven (55%) had H1N1 influenza A-associated pneumonitis. Eighteen (86%) patients survived to hospital discharge. Of the 18 survivors, ten (56%) were discharged to other hospitals and 8 (44%) were discharged directly home. Sequelae and health related quality of life were evaluated for 15 of the 18 (71%) long-term survivors (assessment at median 8 months). Mean SF-36 scores were significantly lower across all domains compared to age and sex matched Australian norms. Mean SF-36 scores were lower (minimum important difference at least 5 points) than previously described ARDS survivors in the domains of general health, mental health, vitality and social function. One patient had long-term disability as a result of ICU acquired weakness. Only 26% of survivors had returned to previous work levels at the time of follow-up.

Conclusions

This ARDS cohort had a high survival rate (86%) after use of ECMO support for reversible refractory hypoxemia. Long term survivors had similar physical health but decreased mental health, general health, vitality and social function compared to other ARDS survivors and an unexpectedly poor return to work.     

Portable miniaturized extracorporeal membrane oxygenation systems for H1N1-related severe acute respiratory distress syndrome: A case series

Background

Technological advances improved the practice of “modern” extracorporeal membrane oxygenation (ECMO). In the present report, we describe the experience of a referral ECMO center using portable miniaturized ECMO systems for H1N1-related severe acute respiratory distress syndrome (ARDS).

Methods

An observational study of all patients with H1N1-associated ARDS treated with ECMO in Hospital S. João (Porto, Portugal) between November 2009 and April 2011 was performed. Extracorporeal membrane oxygenation support was established using either ELS or Cardiohelp systems (Maquet-Cardiopulmonary-AG, Hirrlingen, Germany).

Results

Ten adult patients with severe ARDS secondary to H1N1 infection (Pao₂/fraction of inspired oxygen, 69 mm Hg [56-84]; Murray score, 3.5 [3.5-3.8]) were included, and 60% survived to hospital discharge. Five patients were uneventfully transferred on ECMO from referring hospitals to our center by ambulance. Six patients were treated during the first postpandemic influenza season. All patients were treated with oseltamivir, and 1 received in addition zanamivir. Four patients received corticosteroids. Nosocomial infection was the most common complication (40%). Of the 4 deaths, 2 were caused by hemorrhagic shock; 1, by irreversible multiple organ failure; and 1, by refractory septic shock.

Conclusion

In our experience, ECMO support was a valuable therapeutic option for H1N1-related severe ARDS. The use of portable miniaturized systems allowed urgent rescue of patients from referring hospitals and safe interhospital and intrahospital transport during ECMO support.     

High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation

Objective: We investigated whether a treatment according to a clinical algorithm could improve the low survival rates in acute respiratory distress syndrome (ARDS). Design: Uncontrolled prospective trial. Setting: One university hospital intensive care department. Patients and participants: 122 patients with ARDS, consecutively admitted to the ICU. Interventions: ARDS was treated according to a criteria-defined clinical algorithm. The algorithm distinguished two main treatment groups: The AT-sine-ECMO (advanced treatment without extracorporeal membrane oxygenation) group (n = 73) received a treatment consisting of a set of advanced non-invasive treatment options, the ECMO treatment group (n = 49) received additional extracorporeal membrane oxygenation (ECMO) using heparin-coated systems. Measurements and results: The groups differed in both APACHE II (16 ± 5 vs 18 ± 5 points, p = 0.01) and Murray scores (3.2 ± 0.3 vs 3.4 ± 0.3 points, p = 0.0001), the duration of mechanical ventilation prior to admission (10 ± 9 vs 13 ± 9 days, p = 0.0151), and length of ICU stay in Berlin (31 ± 17 vs 50 ± 36 days, p = 0.0016). Initial PaO₂/FIO₂ was 86 ± 27 mm Hg in AT-sine-ECMO patients that improved to 165 ± 107 mm Hg on ICU day 1, while ECMO patients showed an initial PaO₂/FIO₂ of 67 ± 28 mm Hg and improvement to 160 ± 102 mm Hg was not reached until ICU day 13. Q˙_S/Q˙_T was significantly higher in the ECMO-treated group and exceeded 50 % during the first 14 ICU days. The overall survival rate in our 122 ARDS patients was 75 %. Survival rates were 89 % in the AT-sine ECMO group and 55 % in the ECMO treatment group (p = 0.0000). Conclusions: We conclude that patients with ARDS can be successfully treated with the clinical algorithm and high survival rates can be achieved. Received: 9 April 1997 Accepted: 13 May 1997     

Associations between ventilator settings during extracorporeal membrane oxygenation for refractory hypoxemia and outcome in patients with acute respiratory distress syndrome: a pooled individual patient data analysis

Purpose

Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for patients with acute respiratory distress syndrome (ARDS). The aim of this study was to evaluate associations between ventilatory settings during ECMO for refractory hypoxemia and outcome in ARDS patients.

Methods

In this individual patient data meta-analysis of observational studies in adult ARDS patients receiving ECMO for refractory hypoxemia, a time-dependent frailty model was used to determine which ventilator settings in the first 3 days of ECMO had an independent association with in-hospital mortality.

Results

Nine studies including 545 patients were included. Initiation of ECMO was accompanied by significant decreases in tidal volume size, positive end-expiratory pressure (PEEP), plateau pressure, and driving pressure (plateau pressure ? PEEP) levels, and respiratory rate and minute ventilation, and resulted in higher PaO₂/FiO₂, higher arterial pH and lower PaCO₂ levels. Higher age, male gender and lower body mass index were independently associated with mortality. Driving pressure was the only ventilatory parameter during ECMO that showed an independent association with in-hospital mortality [adjusted HR, 1.06 (95 % CI, 1.03–1.10)].

Conclusion

In this series of ARDS patients receiving ECMO for refractory hypoxemia, driving pressure during ECMO was the only ventilator setting that showed an independent association with in-hospital mortality.

     

Five-year experience with mobile adult extracorporeal membrane oxygenation in a tertiary referral center

IntroductionMobile extracorporeal membrane oxygenation (ECMO) is reserved for critically unstable patients who may not otherwise survive transfer to the ECMO center. We describe our experience with mobile ECMO.MethodsWe retrospectively reviewed adult patients between 2010 and 2014 who were referred for ECMO support and were too unwell for conventional transfer. They were cannulated at their referring center by our team and subsequently transported back to our hospital on ECMO.ResultsA total of 102 patients were put on ECMO by our team. Of 102 patients, 95 (93%) were managed by venovenous ECMO, and 7 (7%), by venoarterial ECMO. The average distance traveled was 195 miles (SD, ± 256.8; range, 3.6-980). Transportation was via road in 77 cases (77%), by air in 22 cases (22%), and in 3 cases (3%) a combination of road and air was used. A double-lumen Avalon cannula was used in 72 patients (70%). One patient had a ventricular tachycardia arrest during cannulation but was successfully resuscitated. There was no mortality or major complications during transfer.ConclusionThe use of mobile ECMO in adult patients is a safe modality for transfer of critically unwell patients. We have safely used double-lumen cannulas in most of these patients.     

Extracorporeal membrane oxygenation (ECMO) pour les syndromes de détresse respiratoire aiguë (SDRA) sévères. L’essai EOLIA (ECMO to rescue Lung Injury in severe ARDS): un essai multicentrique international, randomisé, contrôlé en ouvert

The acute respiratory distress syndrome (ARDS) remains associated with an elevated rate of mortality that may exceed 60% in the most severe cases with a refractory hypoxemia. In these situations, the use of an extracorporeal membrane oxygenation (ECMO), combining a centrifugeal pump and an oxygen membrane, was proposed. The aim of ECMO is to minimize the trauma induced by mechanical ventilation (MV) and to allow the lungs to rest. The objective of this multicenter, international, randomized, open trial is to evaluate the impact on the morbidity and mortality of ECMO, early instituted after the diagnosis of an ARDS with an unfavorable outcome after 3–6 hours despite optimal ventilatory management and maximum medical treatment. Included patients will fulfill the following criteria: ARDS defined according to the usual criteria and PaO₂/FiO₂ ratio < 50 mmHg with FiO₂ ≥ 80% for > 3 hours, despite the optimization of mechanical ventilation and use of adjunctive therapies or PaO₂/FiO₂ < 80 mmHg with FiO₂ ≥ 80% for > 6 hours, despite the optimization of mechanical ventilation and use of adjunctive therapies or pH < 7.25 for > 6 hours (despite an increase of the respiratory rate up to 35/min) resulting from MV settings adjusted to keep a plateau pressure ≤ 32 cmH₂O. In the control arm, standard ARDS management according to the modalities used for the “maximal pulmonary recruitment” group in the EXPRESS trial, will be performed. The primary endpoint is to achieve with ECMO a significantly lower mortality on day 60 following the randomization. With a 80%-power and a 5%-alpha-risk for the hypothesis of ECMO achieving a 20%-absolute mortality reduction and an estimated probability of 60%-mortality in the control arm, the characteristics of the study, calculated with a triangle test, indicate a 90%-probability of stopping the study before the inclusion of 220 subjects. This project will be conducted within the REVA (European network for research in mechanical ventilation).     

Correlation of patient-reported outcome measures to performance-based function in critical care survivors: PREDICTABLE

BackgroundEstablishing sequela following critical illness is a public health priority; however, recruitment and retention of this cohort make assessing functional outcomes difficult. Completing patient-reported outcome measures (PROMs) via telephone may improve participant and researcher involvement; however, there is little evidence regarding the correlation of PROMs to performance-based outcome measures in critical care survivors.ObjectivesThe objective of this study was to assess the relationship between self-reported and performance-based measures of function in survivors of critical illness.MethodsThis was a nested cohort study of patients enrolled within a previously published study determining predictors of disability-free survival. Spearman's correlation (r_s) was calculated between four performance-based outcomes (the Functional Independence Measure [FIM], 6-min walk distance [6MWD], Functional Reach Test [FRT], and grip strength) that were collected during a home visit 6 months following their intensive care unit admission, with two commonly used PROMs (World Health Organization Disability Assessment Scale 2.0 12 Level [WHODAS 2.0] and EuroQol-5 Dimension-5 Level [EQ-5D-5L]) obtained via phone interview (via the PREDICT study) at the same time point.ResultsThere were 38 PROMs obtained from 40 recruited patients (mean age = 59.8 ± 16 yrs, M:F = 24:16). All 40 completed the FIM and grip strength, 37 the 6MWD, and 39 the FRT. A strong correlation was found between the primary outcome of the WHODAS 2.0 with all performance-based outcomes apart from grip strength where a moderate correlation was identified. Although strong correlations were also established between the EQ-5D-5L utility score and the FIM, 6MWD, and FRT, it only correlated weakly with grip strength. The EQ-5D overall global health rating only had very weak to moderate correlations with the performance-based outcomes.ConclusionThe WHODAS 2.0 correlated stronger across multiple performance-based outcome measures of functional recovery and is recommended for use in survivors of critical illness.