Postpartum extracorporeal membrane oxygenation of a woman with COVID-19-related acute respiratory distress syndrome: A case report

Introduction:Patients with coronavirus disease (COVID-19) may develop acute respiratory distress syndrome (ARDS). There have been few reports of postpartum woman with ARDS secondary to COVID-19 who required respiratory support using veno-venous extracorporeal membrane oxygenation (ECMO). We present the case of a 31-year-old woman who was admitted to hospital at 35 weeks gestation with ARDS secondary to COVID-19 and required ECMO during the postpartum period.Patient concerns:The patient had obvious dyspnea, accompanied by chills and fever. Her dyspnea worsened and her arterial oxygen saturation decreased rapidly.Diagnosis:ARDS secondary to COVID-19.Interventions:Emergency bedside cesarean section. Medications included immunotherapy (thymosin α 1), antivirals (lopinavir/ritonavir and ribavirin), antibiotics (imipenem-cilastatin sodium and vancomycin), and methylprednisolone. Ventilatory support was provided using invasive mechanical ventilation. This was replaced by venous-venous ECMO 5 days postpartum. ECMO management focused on blood volume control, coagulation function adjustment, and airway management.Outcomes:The patient was successfully weaned for ECMO and the ventilator and made a good recovery.Conclusion:Special care, including blood volume control, coagulation function adjustment, and airway management, should be provided to postpartum patients with ARDS secondary to COVID-19 who require ECMO support.     

Adenovirus Pneumonia Complicated With Acute Respiratory Distress Syndrome: A Case Report

Severe adenovirus infection in children can manifest with acute respiratory distress syndrome (ARDS) and respiratory failure, leading to the need for prolonged mechanical support in the form of either mechanical ventilation or extracorporeal life support. Early extracorporeal membrane oxygenation (ECMO) intervention for children with ARDS should be considered if selection criteria fulfill.We report on a 9-month-old boy who had adenovirus pneumonia with rapid progression to ARDS. Real-time polymerase chain reaction tests of sputum and pleural effusion samples confirmed adenovirus serotype 7. Chest x-rays showed progressively increasing infiltrations and pleural effusions in both lung fields within 11 days. Because conventional ARDS therapies failed, we initiated ECMO with high-frequency oscillatory ventilation (HFOV) for 9 days. Chest x-rays showed gradual improvements in lung expansion.This patient was subsequently discharged after a hospital stay of 38 days. Post-ECMO and adenovirus sequelae were followed in our outpatient department.Adenovirus pneumonia in children can manifest with severe pulmonary morbidity and respiratory failure. The unique lung recruitment by HFOV can be a useful therapeutic option for severe ARDS patients when combined with sufficient lung rest provided by ECMO.     

The role of extracorporeal membrane oxygenation in severe pulmonary coccidioidomycosis

Background

Severe coccidioidal pneumonia with acute respiratory distress syndrome (ARDS) is associated with high mortality. Extracorporeal membrane oxygenation (ECMO) has been applied successfully to other severe fungal pneumonia associated with ARDS. We review our experience with the use of ECMO in severe coccidioidal ARDS.

COVID-19 et assistance circulatoire

Extracorporeal membrane oxygenation (ECMO) is mainly used as a rescue therapy in COVID-19 patients with severe acute respiratory distress syndrome (ARDS). More rarely, COVID-19 can be complicated by hemodynamic failure due to fulminant myocarditis or massive pulmonary embolism necessitating the implantation of venous-arterial ECMO. The management of ECMO during the COVID-19 pandemic is challenging due to some specificities related to the disease characteristics, such as the management of anticoagulation in patients with a hypercoagulable state and an increased risk of venous thromboembolism. In large retrospective cohorts, survival of ECMO-rescued COVID-19 patients with ADRS was reported to be similar to that reported in previous studies on ECMO support for severe ARDS. Full consideration of ECMO candidacy is crucial for appropriate allocation of resources.     

Awake extracorporeal membrane oxygenation in patients with severe postoperative acute respiratory distress syndrome

Background

A clinical trial of extracorporeal membrane oxygenation (ECMO) as an alternative ventilator tool is being performed as a new indication for ECMO. The purpose of this study was to evaluate the feasibility of awake ECMO to increase the success rate of weaning patients from ECMO and ventilator care during treatment of postoperative severe acute respiratory distress syndrome (ARDS).

Methods

We retrospectively analyzed the clinical reports of 10 patients who underwent awake ECMO due to postoperative ARDS between August 2012 and May 2015. We analyzed patient history, the partial arterial pressure of oxygen (PaO₂)/fraction of inspired oxygen (FiO₂) ratio, and patient outcome.

Results

Seven patients (70%) were weaned from ECMO without difficulty; one patient failed to maintain awake ECMO, was re-intubated after 2 days of awake ECMO, and was re-tried on awake ECMO after 4 days of ventilator care. We weaned that patient from ECMO 2 days later. We weaned a total of eight patients (80%) from awake ECMO. The ECMO duration of surviving patients was 9.13±2.2 days (range, 6–12 days), and mean ventilator use duration was 6.8±4.7 days (range, 2–16 days). Two cases failed awake ECMO and died due to disease aggravation.

Conclusions

Awake ECMO was a useful weaning strategy after severe postoperative ARDS, as it avoids long-duration use of mechanical ventilation. Additionally, it is possible for patients to breathe spontaneously, which might prevents respiratory muscle dystrophy.     

First successful treatment of a COVID-19 pregnant woman with severe ARDS by combining early mechanical ventilation and ECMO

The novel coronavirus (COVID-19) has become a global pandemic outbreak. Patients with COVID-19 are prone to progress to acute respiratory distress syndrome (ARDS), and even severe ARDS with ineffective mechanical ventilation, and an extremely high mortality. Extracorporeal membrane oxygenation (ECMO) provides effective respiratory support and saves time for the treatment of severe COVID-19. The present study reports that a 31-year-old pregnant female infected by COVID-19, who suffered from fever, dyspnea, and rapid ARDS. The patient's pulmonary function gradually recovered by combining early mechanical ventilation and ECMO, and finally, this patient was successfully weaned from ECMO and the ventilator. No fibrosis lesions were found in the chest CT, and the patient recovered very well after leaving from the hospital for one month.     

重症急性呼吸窘迫综合征体外膜肺治疗的探讨

目的 回顾性分析体外膜氧合(ECMO)在重症急性呼吸窘迫综合征(ARDS)治疗中的作用.方法 应用股静脉-股动脉途径的ECMO支持对1例吸入烟雾弹致严重ARDS患者治疗41 d.连续观察患者血液动力学、肺影像学、呼吸机参数、经皮脉氧氧饱和度、酸碱平衡、血乳酸含量以及心、肝、肾、脑功能的变化.结果 ECMO支持技术可使重症ARDS患者较长时间维持生理水平的动脉血气、组织氧供及酸碱平衡,保持良好的心、肺、肾、脑功能,但患者在行ECMO支持治疗的第41天因严重的肺部感染并可能的脑出血失去继续治疗的价值而终止治疗.结论 ECMO可提供有效的肺功能支持,可为ARDS患者肺的恢复和临床进一步处理创造了机会.出血与栓塞是维持ECMO顺利运行的关键问题.     

Continuous Renal Replacement Therapy During Extracorporeal Membrane Oxygenation in Patients Treated in Medical Intensive Care Unit: Technical Considerations

Extracorporeal membrane oxygenation (ECMO) is used as a salvage therapy in refractory acute respiratory distress syndrome (ARDS). Although technological progress in the ECMO systems improved the survival rate, prognosis is still significantly worsened by acute kidney injury (AKI), particularly if renal replacement therapy (RRT) is required. There are no exact guidelines recommending which techniques of ECMO and continuous RRT (CRRT) should be used for management of AKI coexisting with respiratory or circulatory failure, and how to combine them. The aim of this review is to describe methods of CRRT and ECMO simultaneous application, and to present advantages of various technical approaches versus possible complications.     

不同病因导致急性呼吸窘迫综合征应用体外膜式氧合治疗体会

目的:观察不同病因引起急性呼吸窘迫综合征(ARDS)的患者,应用体外膜式氧合(ECMO)的治疗效果。方法:回顾性分析2007年6月至2008年8月我院3例ARDS应用ECMO病例。发生原因分别是重症肺炎、胸腹联合创伤后合并呼吸机相关性肺炎(VAP)、以及肺栓塞肺动脉内膜血栓剥脱术后灌注肺;观察应用ECMO前基础状态(Base)、用后8 h、24 h、48 h及72 h动脉血气分析、血压、脉搏和呼吸机调整参数。结果:应用ECMO后,例1重症肺炎患者8 h、24 h、48 h及72 h血压、脉搏及氧合等项指标平稳,但ECMO参数下调时,缺氧状态无缓解,最终ECMO辅助14 d后死亡;例2胸腹联合创伤后VAP合并ARDS患者和例3肺栓塞术后灌注肺患者,ECMO辅助8 h、24 h、48 h、72 h血压、脉搏、氧合等项指标明显改善,分别于ECMO辅助4 d后和24 h后停机。结论:不同病因导致的ARDS应用ECMO后可能结果有所不同。ECMO能改善ARDS患者氧合和气体交换,减轻肺部病理损伤,减轻机体因低氧血症带来的多器官损伤,为治疗原发病赢得时间。     

Extracorporeal Membrane Oxygenation Used in Acute Respiratory Distress Syndrome with COVID-19: A Systematic Review and Meta-Analysis

IntroductionProtective pulmonary mechanical ventilation, higher positive end-expiratory pressure, neuromuscular blockade, prone positioning, and pulmonary recruitment procedures are all strategies in severe COVID-19 cases. Extracorporeal Membrane Oxygenation (ECMO) can be seen as an alternative to traditional treatment in certain patients when conventional therapy fails. We present a study that intends to systematically review and meta-analysis ECMO use in COVID-19 patients.MethodsWe search major medical databases (Cochrane Library, PubMed, EMBASE, MedRxiv) for clinical trials that were released between January 2020 until February 2021, had full-text availability, were written in English, and humans studies.We used National Heart, Lung, and Blood Institute (NHLBI) quality evaluation methods for retrospective cohort and cross-sectional studies to evaluate the quality of the articles. In addition, we used the Mantel–Haenszel random-effects meta-analysis of using RevMan 5.4.ResultsA total of 33 studies involving 3090 patients were included in the systematic review and six studies in the meta-analysis. There were 828 patients admitted to the ICU, of which 779 patients had ARDS (94%). Of the total study, 527 patients received ECMO therapy (17%). ARDS incidence was associated with complications during ICU care compared to non-ICU care (OR 107.98; 95% CI 55.51–210.03; p < 0.00001). Indirect comparisons, the incidence of mortality was associated with ECMO compared with non-ECMO (OR 15.79; 95% CI 4.21–59.28; p < 0.0001).ConclusionThe incidence of ARDS was associated with complications during ICU stay, and the incidence of mortality was associated with ECMO. Further study about mechanisms involving illness and death of patients from COVID-19 is needed.     

Treatment of a case presenting as critical adenoviral ARDS using Cidofovir with early combinatorial prone ventilation and ECMO

Here, we report a case of adenoviral pneumonia associated with critical ARDS treated with Cidofovir, prone ventilation and extracorporeal membrane oxygenation (ECMO). The patient responded well to therapy and recovered without further complications. Cidofovir, with early prone ventilation and ECMO support, may be a therapeutic option for patients with critical ARDS related to adenoviral pneumonia.     

体外膜肺氧合技术在重症呼吸衰竭患者治疗的应用进展

从体外膜肺氧合(ECMO)治疗的基本原理及其发展、ECMO 技术应用于重症呼吸衰竭的适应证等方面综述了体外膜肺氧合技术在重症呼吸衰竭患者治疗中的应用进展。体外膜肺氧合技术治疗 ARDS 有独特的优势和良好的效果,并且是一种简单、安全的技术,随着体外膜肺技术的成熟,其并发症逐渐减少。     

Protocol-driven daily optimisation of venovenous extracorporeal membrane oxygenation blood flows: an alternate paradigm?

Venovenous extracorporeal membrane oxygenation (VV ECMO) is now an established modality of support for patients with the who are failing evidence-based conventional therapies. Minimising ventilator-induced lung injury is the guiding principle behind patient management with VV ECMO. Patients with acute respiratory distress syndrome (ARDS) supported with VV ECMO are liberated from ECMO at a stage when native lungs have recovered sufficiently to support physiologic demands and the risks of iatrogenic lung injuries after discontinuation of ECMO are perceived to be small. However, native lung recovery is a dynamic process and patients rely on varying degrees of contributions from both native lungs and ECMO for gas exchange support. Patients often demonstrate near total ECMO dependence for oxygenation and decarboxylation early in the course of the illness and this may necessitate higher ECMO blood flow rates (EBFRs). Although, reliance on high EBFR for oxygenation support may remain variable over the course of ECMO, blood flow requirements typically diminish over time as native lungs start to recover. Currently, protocol-driven modulation of the EBFR based on changing physiologic needs is not common practice and consequently patients may remain on higher than physiologically necessary EBFR. This exposes the patient to potential risks because maintaining higher blood flows often requires a less restrictive fluid balance and deeper sedation. Both may be harmful in the setting of recovery from ARDS. In this article, we propose a strategy that involves daily assessments of native lung function and a protocol-driven daily optimisation of EBFR. This is followed by optimisation of sweep gas flow rate (SGFR) and the fraction of delivered oxygen in the sweep gas (FdO₂). This staged approach to weaning VV ECMO allows us to fully utilise the “decoupling” of oxygenation and decarboxylation that is possible only during extracorporeal support. This approach may benefit patients by allowing for greater fluid restriction, more aggressive fluid removal, expedited weaning of sedation and neuromuscular blocking agents (NMBAs), and early physical rehabilitation. Ultimately, prospective studies are needed to evaluate optimal VV ECMO weaning practices     

Extracorporeal membrane oxygenation as a rescue therapy for leukaemic children with pulmonary failure

In patients with leukaemia, acute respiratory distress syndrome (ARDS) secondary to intensified chemotherapy-induced immunosuppression is a devastating disorder resulting in high morbidity and mortality. Compared to standard indications for extracorporeal membrane oxygenation (ECMO), cytopenia further increases the risks of infection and bleeding. We describe the use of ECMO in four children with ARDS and leukaemia. Two patients (50%) survived, pulmonary function recovered and they are in prolonged first remission. The two other patients died from ARDS and pulmonary leukaemic infiltration. Although ECMO support is a high-risk setup for nosocomial infection we observed no additional septic episodes. All patients had a highly increased demand for packed platelet and red blood cell transfusions. This increased demand and unmanageable chronic bleeding into both lungs in one patient were probably caused by a combination of coagulopathy from the primary illness, the use of anticoagulants, chemotherapy-induced cytopenia, and a reduced survival rate of platelets and red cells due to permanent contact to foreign surface. We concluded that ECMO is a supportive tool to reduce the incidence of early death, treatment-related mortality and, ultimately, to improve overall survival in childhood leukaemia.     

体外膜肺氧合治疗ARDS的实验研究

目的：探讨体外膜肺氧合（ECMO）治疗ARDS的有效性和可行性。方法：采用油酸注入法制备犬ARDS模型，将15只犬随机分为3组：对照组（n=5）、模型组（n=5）及V-VECMO治疗组，通过监测血气指标、血流动力学指标、血管外肺水含量及肺顺应性指标，评价V-VECMO疗效。结果：V-VECMO明显提高了动脉和混合静脉血氧分压，增加氧供，增加心排血量，降低肺血管阻力，减轻肺水肿，肺功能明显改善。结论：ECMO治疗ARDS有效和可行，为临床治疗ARDS提供了新思路。     

Respiratorische Insuffizienz bei Neugeborenen sowie bei S?uglingen und Kleinkindern

Summary RDS of the premature, respiratory disorders of the term baby, and ARDS are the main causes of lung failure in infancy and childhood. Essentially gas exchange problems based on these disorders can be managed by conservative ventilator therapy adapted to the pathophysiologic condition of the patient. If this therapy fails, ECMO is still successful in respiratory diseases of the term or near term baby. Only in this group of patients is the use of iNO of HFOV also proven to be successful. Zusammenfassung Infantiles Atemnotsyndrom des Frühgeborenen, Atemstörungen des reifen Neugeborenen und ARDS des Säuglings- und Kindesalters sind drei Formen der akuten Atemstörungen im Kindesalter. Im wesentlichen werden Gaswechselprobleme im Rahmen dieser Grundkrankheiten durch konservative, an die Pathophysiologie angepaßte Beatmungstherapie bewältigt. Bei Versagen dieser Therapie ist ECMO im Rahmen der Atemstörung des reifen Neugeborenen nach wie vor erfolgreich. Lediglich für diese Patientengruppe ist die Wirksamkeit von inhalativem NO (iNO) oder hochfrequenter Oszillationsbeatmung (HFOV) belegt.     

Kritische Atemst?rungen im S?uglings- und Kindesalter

Infants and children who require mechanical ventilation represent high-risk populations who have significant morbidity and mortality. Experienced handling of conventional ventilation including high-frequency oscillation ventilation and initiation of newer treatment options such as surfactant or nitric oxide has led to some improvements. Nevertheless extracorporeal membrane oxygenation (ECMO) may be a life-saving technology in patients with respiratory failure refractory to maximal medical therapy. This article demonstrates clinical management and discusses selection criteria for ECMO in critically ill infants and children suffering from acute respiratory distress syndrome (ARDS).     

危重型新型冠状病毒肺炎的治疗思考(一)

新型冠状病毒肺炎(COVID-19)在武汉感染流行并迅速蔓延至全国,部分病例可发生急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS),甚至引起死亡。在此我们结合一线的救治体会,给大家分享危重型NCP的治疗经验。需选择最佳呼吸支持方式,但气管插管时机的把握及插管时的防护是两个难点;高水平呼气末正压通气(PEEP)、俯卧位效果不佳的患者可行体外膜氧合(ECMO)支持。对于机械通气的NCP患者,制定合理的镇静镇痛策略,谵妄不容忽视。此外,危重型COVID-19患者体内存在炎性因子的上调,但肾脏替代治疗的效果还需临床研究进一步证实。     

Extracorporeal membrane oxygenation: current clinical practice, coding, and reimbursement

Extracorporeal membrane oxygenation (ECMO) is a technique for providing life support for patients experiencing both pulmonary and cardiac failure by maintaining oxygenation and perfusion until native organ function is restored. ECMO is used routinely at many specialized hospitals for infants and less commonly for children with respiratory or cardiac failure from a variety of causes. Its usage is more controversial in adults, but select medical centers have reported favorable findings in patients with ARDS and other causes of severe pulmonary failure. ECMO is also rarely used as a rescue therapy in a small subset of adult patients with cardiac failure. This article will review the current uses and techniques of ECMO in the critical care setting as well as the evidence supporting its usage. In addition, current practice management related to coding and reimbursement for this intensive therapy will be discussed.     

The use of life-saving extracorporeal membrane oxygenation (ECMO) for pregnant woman with status asthmaticus

Introduction: Status asthmaticus can develop into a life-threatening disorder that requires mechanical ventilation. Severe respiratory failure during pregnancy can worsen maternal and fetal outcomes. Previous case studies have demonstrated extracorporeal membrane oxygenation (ECMO) as a life-saving measure for pregnant women with acute respiratory distress syndrome (ARDS) as well as non-pregnant patients with status asthmaticus. Case study: A 25-year-old woman, who was 5 weeks pregnant, was admitted with status asthmaticus and severe hypercapnic respiratory failure. Despite rescue therapies such as pressure control ventilation with high inspiratory pressures, inhaled beta2 agonists and antimuscarinic drugs, intravenous salbutamol, methylprednisolone and magnesium sulfate, her condition gradually deteriorated. Veno-venous ECMO was initiated for respiratory support and the patient's clinical condition as well as the gas exchange improved within the next few days. ECMO was removed and the patient was extubated after 2 days. Sonography, however, revealed a retrochorial hematoma; the patient was diagnosed with abortus imminens and successfully treated with magnesium substitution and bed rest. Finally, she gave birth to a healthy boy at 38 weeks of gestation. Conclusions: This is the first case report on the successful use of ECMO in a pregnant woman with severe respiratory insufficiency due to status asthmaticus, who failed to respond to invasive mechanical ventilation and maximum pharmacological treatment. Despite this life-threatening condition, the use of ECMO in our patient has greatly improved the chance of survival for the mother and the baby, who was born without any complications.