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Background: A combination of prone positioning (PP) and venovenous extracorporeal membrane oxygenation (VV-ECMO) is safe, feasible, and associated with potentially improved survival for severe acute respiratory distress syndrome (ARDS). However, whether ARDS patients, especially non-COVID-19 patients, placed in PP before VV-ECMO should continue PP after a VV-ECMO connection is unknown. This study aimed to test the hypothesis that early use of PP during VV-ECMO could increase the proportion of patients successfully weaned from ECMO support in severe ARDS patients who received PP before ECMO. Methods: In this prospective observational study, patients with severe ARDS who were treated with VV-ECMO were divided into two groups: the prone group and the supine group, based on whether early PP was combined with VV-ECMO. The proportion of patients successfully weaned from VV-ECMO and 60-day mortality were analyzed before and after propensity score matching. Results: A total of 165 patients were enrolled, 50 in the prone and 115 in the supine group. Thirty-two (64%) and 61 (53%) patients were successfully weaned from ECMO in the prone and the supine groups, respectively. The proportion of patients successfully weaned from VV-ECMO in the prone group tended to be higher, albeit not statistically significant. During PP, there was a significant increase in partial pressure of arterial oxygen (PaO2) without a change in ventilator or ECMO settings. Tidal impedance shifted significantly to the dorsal region, and lung ultrasound scores significantly decreased in the anterior and posterior regions. Forty-five propensity score-matched patients were included in each group. In this matched sample, the prone group had a higher proportion of patients successfully weaned from VV-ECMO (64.4% vs. 42.2%; P = 0.035) and lower 60-day mortality (37.8% vs. 60.0%; P = 0.035). Conclusions: Patients with severe ARDS placed in PP before VV-ECMO should continue PP after VV-ECMO support. This approach could increase the probability of successful weaning from VV-ECMO. Trial Registration: ClinicalTrials.Gov: NCT04139733. Registered 23 October 2019. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) is used in critically ill patients with coronavirus disease 2019 (COVID-19) with acute respiratory distress syndrome unresponsive to other interventions. However, a COVID-19 infection may result in a differential tolerance to both medical treatment and ECMO management. The aim of this study was to compare outcomes (mortality, organ failure, circuit complications) in patients on ECMO with and without COVID-19 infection, either by venovenous (VV) or venoarterial (VA) cannulation. This is a multicenter, retrospective analysis of a national database of patients placed on ECMO between May 2020 and January 2022 within the United States. Nine-hundred thirty patients were classified as either Pulmonary (PULM, n = 206), Cardiac (CARD, n = 279) or COVID-19 (COVID, n = 445). Patients were younger in COVID groups: PULM = 48.4 ± 15.8 years versus COVID = 44.9 ± 12.3 years, p = 0.006, and CARD = 57.9 ± 15.4 versus COVID = 46.5 ± 11.8 years, p < 0.001. Total hours on ECMO were greatest for COVID patients with a median support time two-times higher for VV support (365 [101, 657] hours vs 183 [63, 361], p < 0.001), and three times longer for VA support (212 [99, 566] hours vs 70 [17, 159], p < 0.001). Mortality was highest for COVID patients for both cannulation types (VA-70% vs 51% in CARD, p = 0.041, and VV-59% vs PULM-42%, p < 0.001). For VA supported patients hepatic failure was more often seen with COVID patients, while for VV support renal failure was higher. Circuit complications were more frequent in the COVID group as compared to both CARD and PULM with significantly higher circuit change-outs, circuit thromboses and oxygenator failures. Anticoagulation with direct thrombin inhibitors was used more often in COVID compared to both CARD (31% vs 10%, p = 0.002) and PULM (43% vs 15%, p < 0.001) groups. This multicenter observational study has shown that COVID patients on ECMO had higher support times, greater hospital mortality and higher circuit complications, when compared to patients managed for either cardiac or pulmonary lesions. [ABSTRACT FROM AUTHOR]

Background: The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) remains controversial in trauma patients with acute respiratory distress syndrome (ARDS). Here, we aimed to investigate the therapeutic benefits of VV ECMO and the factors affecting patient outcomes. Methods: From 2017 to 2019, 21/1938 trauma patients (median age: 47 years; 18 men) at a level I trauma center received VV ECMO for post-traumatic ARDS. Demographic, injury-specific, ECMO, and outcome data were prospectively collected and retrospectively reviewed to analyze the factors affecting hospital mortality and ECMO results. Results: 19 patients (90.5%) were successfully weaned off ECMO; 16 patients (76.2%) survived to discharge. In univariate analysis, there was a significant difference in survival between the groups with a Trauma and Injury Severity Score (TRISS) ⩾0.5 and TRISS <0.5 (p = 0.05). The area under the receiver operating characteristic curve (AUC) for both TRISS and Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) scores for death was 0.78. In those who failed ECMO weaning, the AUCs of the TRISS and RESP scores were 0.90 and 0.80, respectively. Conclusions: In patients with ARDS caused by severe trauma and supported by VV ECMO, survival is associated with TRISS; TRISS and RESP scores may be predictive of mortality and failure in ECMO weaning. [ABSTRACT FROM AUTHOR]

Background: A strategy that limits tidal volumes and inspiratory pressures, improves outcomes in patients with the acute respiratory distress syndrome (ARDS). Extracorporeal carbon dioxide removal (ECCO2R) may facilitate ultra-protective ventilation. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of venovenous ECCO2R in supporting ultra-protective ventilation in moderate-to-severe ARDS. Methods: MEDLINE and EMBASE were interrogated for studies (2000–2021) reporting venovenous ECCO2R use in patients with moderate-to-severe ARDS. Studies reporting ≥10 adult patients in English language journals were included. Ventilatory parameters after 24 h of initiating ECCO2R, device characteristics, and safety outcomes were collected. The primary outcome measure was the change in driving pressure at 24 h of ECCO2R therapy in relation to baseline. Secondary outcomes included change in tidal volume, gas exchange, and safety data. Results: Ten studies reporting 421 patients (PaO2:FiO2 141.03 mmHg) were included. Extracorporeal blood flow rates ranged from 0.35-1.5 L/min. Random effects modelling indicated a 3.56 cmH2O reduction (95%-CI: 3.22–3.91) in driving pressure from baseline (p <.001) and a 1.89 mL/kg (95%-CI: 1.75–2.02, p <.001) reduction in tidal volume. Oxygenation, respiratory rate and PEEP remained unchanged. No significant interactions between driving pressure reduction and baseline driving pressure, partial pressure of arterial carbon dioxide or PaO2:FiO2 ratio were identified in metaregression analysis. Bleeding and haemolysis were the commonest complications of therapy. Conclusions: Venovenous ECCO2R permitted significant reductions in ∆P in patients with moderate-to-severe ARDS. Heterogeneity amongst studies and devices, a paucity of randomised controlled trials, and variable safety reporting calls for standardisation of outcome reporting. Prospective evaluation of optimal device operation and anticoagulation in high quality studies is required before further recommendations can be made. [ABSTRACT FROM AUTHOR]

In patients with pediatric acute respiratory distress syndrome (PARDS) and hemodynamic compromise who need venoarterial (VA) extracorporeal life support (ECLS), we have adopted a strategy to promote early VA-to-venovenous (VV) conversion since 2018. A single-center retrospective review was performed of all 22 patients who underwent ECLS for PARDS from 2008 to 2019. Variables were analyzed to determine factors affecting initial cannulation mode and in-hospital mortality. Outcomes were compared between before and after 2018. Of the 22 patients, 9 patients underwent initial VA-support. Small patient size and severe cardiopulmonary compromise prior to ECLS favored initial VA- over VV-support. Lactate level and vasoactive inotrope score at 24 hours post-ECLS initiation predicted in-hospital mortality. After 2018, all five patients with initial VA-support were converted to VV-support at 4.4 ± 1.3 days post-ECLS initiation without complications. In-hospital mortality decreased after 2018 (3/9) compared with before (10/13) (p = 0.041) despite longer ECLS run time (723.4 ± 384.2 vs 286.5 ± 235.1 hours, p = 0.003). The number of ECLS-related complications per ECLS 1000 run hours decreased after 2018 (7.2 ± 4.2 vs 46.9 ± 66.5, p = 0.063). Our strategy to promote early VA-to-VV conversion may be worth further evaluation in larger cohort studies. [ABSTRACT FROM AUTHOR]

Objective: There is a paucity of clinical data on critically ill patients with COVID-19 requiring extracorporeal life support.Methods: A statewide multi-institutional collaborative for COVID-19 patients was utilized to obtain clinical data on the first 10 critically ill COVID-19 patients who required extracorporeal membrane oxygenation (ECMO).Results: Of the first 10 patients that required ECMO for COVID-19, the age ranged from 31 to 62 years with the majority (70%) being men. Seven (70%) had comorbidities. The majority (80%) of patients had known sick contact and exposure to COVID-19 positive patients or traveled to pandemic areas inside the United States within the 2 weeks before symptom onset. None of the patients were healthcare workers. The most common symptoms leading to the presentation were high fever ≥103°F (90%), cough (80%) and dyspnea (70%), followed by fatigue and gastrointestinal symptoms (both 30%), myalgia, loss of taste, pleuritic chest pain, and confusion (all 10%). All patients had bilateral infiltrates on chest X-rays suggestive of interstitial viral pneumonia. All patients were cannulated in the venovenous configuration. Two (20%) patients were successfully liberated from ECMO support after 7 and 10 days, respectively, and one (10%) patient is currently on a weaning course. One patient (10%) died after 9 days on ECMO from multiorgan dysfunction.Conclusions: These preliminary multi-institutional data from a statewide collaborative offer insight into the clinical characteristics of the first 10 patients requiring ECMO for COVID-19 and their initial clinical course. Greater morbidity and mortality is likely to be seen in these critically ill patients with longer follow-up. [ABSTRACT FROM AUTHOR]

Background: RESP score and PRESERVE score have been validated for veno-venous Extracorporeal Membrane Oxygenation in severe ARDS to assume individual mortality risk. ARDS patients with low-flow Extracorporeal Carbon Dioxide Removal, especially pumpless Extracorporeal Lung Assist, have also a high mortality rate, but there are no validated specific or general outcome scores. This retrospective study tested whether these established specific risk scores can be validated for pumpless Extracorporeal Lung Assist in ARDS patients in comparison to a general organ dysfunction score, the SOFA score. Methods: In a retrospective single center cohort study we calculated and evaluated RESP, PRESERVE, and SOFA score for 73 ARDS patients with pumpless Extracorporeal Lung Assist treated between 2002 and 2016 using the XENIOS iLA Membrane Ventilator. Six patients had a mild, 40 a moderate and 27 a severe ARDS according to the Berlin criteria. Demographic data and hospital mortality as well as ventilator settings, hemodynamic parameters, and blood gas measurement before and during extracorporeal therapy were recorded. Results: Pumpless Extracorporeal Lung Assist of mechanical ventilated ARDS patients resulted in an optimized lung protective ventilation, significant reduction of PaCO2, and compensation of acidosis. Scoring showed a mean score of alive versus deceased patients of 3 ± 1 versus − 1 ± 1 for RESP (p < 0.01), 3 ± 0 versus 6 ± 0 for PRESERVE (p < 0.05) and 8 ± 1 versus 10 ± 1 for SOFA (p < 0.05). Using receiver operating characteristic curves, area under the curve (AUC) was 0.78 (95% confidence interval (CI) 0.67–0.89, p < 0.01) for RESP score, 0.80 (95% CI 0.70–0.90, p < 0.0001) for PRESERVE score and 0.66 (95% CI 0.53–0.79, p < 0.05) for SOFA score. Conclusions: RESP and PRESERVE scores were superior to SOFA, as non-specific critical care score. Although scores were developed for veno-venous ECMO, we could validate RESP and PRESERVE score for pumpless Extracorporeal Lung Assist. In conclusion, RESP and PRESERVE score are suitable to estimate mortality risk of ARDS patients with an arterio-venous pumpless Extracorporeal Carbon Dioxide Removal. [ABSTRACT FROM AUTHOR]

BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used when mechanical ventilation can no longer support oxygenation or ventilation, or if the risk of ventilator- induced lung injury is considered excessive. The optimum mechanical ventilation strategy once on ECMO is unknown. We sought to describe the practice of mechanical ventilation in children on VV-ECMO and to determine whether mechanical ventilation practices are associated with clinical outcomes. METHODS: We conducted a multicenter retrospective cohort study in 10 pediatric academic centers in the United States. Children age 14 d through 18 y on VV-ECMO from 2011 to 2016 were included. Exclusion criteria were preexisting chronic respiratory failure, primary diagnosis of asthma, cyanotic heart disease, or ECMO as a bridge to lung transplant. RESULTS: Conventional mechanical ventilation was used in about 75% of children on VV-ECMO; the remaining subjects were managed with a variety of approaches. With the exception of PEEP, there was large variation in ventilator settings. Ventilator mode and pressure settings were not associated with survival. Mean ventilator FIO2 on days 1–3 was higher in nonsurvivors than in survivors (0.5 vs 0.4, P = .009). In univariate analysis, other risk factors for mortality were female gender, higher Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS), diagnosis of cancer or stem cell transplant, and number of days intubated prior to initiation of ECMO (all P < .05). In multivariate analysis, ventilator FIO2 was significantly associated with mortality (odds ratio 1.38 for each 0.1 increase in FIO2 , 95% CI 1.09-1.75). Mortality was higher in subjects on high ventilator FIO2 (≥ 0.5) compared to low ventilator FIO2 (> 0.5) (46% vs 22%, P = .001). CONCLUSIONS: Ventilator mode and some settings vary in practice. The only ventilator setting associated with mortality was FIO2 , even after adjustment for disease severity. Ventilator FIO2 is a modifiable setting that may contribute to mortality in children on VV-ECMO. [ABSTRACT FROM AUTHOR]

BACKGROUND: The value of ultrasound in assessing lung aeration of patients with ARDS who require venovenous extracorporeal membrane oxygenation (ECMO) has, to our knowledge, never been studied. The objective of the study was to evaluate by using ultrasound lung aeration at ECMO initiation and withdrawal in subjects with severe ARDS supported by venovenous ECMO. METHODS: Fifty subjects were included in this pilot retrospective study. The lung ultrasound aeration score (LUS) and respiratory variables were collected at ECMO initiation (T0) and ECMO withdrawal (T1). The LUS at T0 between the subjects who survived to ICU discharge and those who died in ICU was compared. The relationship between changes in LUS and changes in ... from T0 to T1 was assessed. RESULTS: The ICU mortality was 34%. The LUS at T0 did' not differ between survivors and non-survivors (median 22 [interquartile range] {IQR} 19-26 vs median 24 [IQR, 19-28]; P = .60). From T0 to T1, the LUS decreased significantly in survivors (median 22 [IQR, 19-26] vs median 16 [IQR, 13-19]; P < .001), it decreased moderately in non-survivors who were weaned off ECMO (median 26 [24-29]) vs median 22 (IQR, 17-24), P = .031), and remained stable in those who died during ECMO (median 25 [IQR, 19-29] vs median 25 [IQR, 23-31]; P = .22). Changes in ... were not related to changes in the LUS between T0 and T1. CONCLUSIONS: At the time of ECMO placement, the subjects who survived ARDS had aeration loss close to that observed in the subjects who did not survive. At the time of ECMO withdrawal, there was a significant improvement in lung aeration in the survivors, whereas a severe loss of lung aeration persisted in the non-survivors, although some were weaned off ECMO. Lung ultrasound provided a valuable tool for bedside assessment of lung aeration in subjects supported by ECMO. [ABSTRACT FROM AUTHOR]

Purpose: Extracorporeal membrane oxygenation (ECMO) is used as temporary cardiorespiratory support in critically ill patients. Little is known about population-level short- and long-term outcomes following ECMO, including healthcare use and health system cost across a wide range of sectors.Methods: Population-based cohort study in Ontario, Canada (October 1, 2009-March 31, 2017) of adult patients (≥ 18 years) receiving ECMO for cardiorespiratory support. We captured outcomes through linkage to health administrative databases. Primary outcome was mortality during hospitalization, as well as at 7 days, 30 days, 1 year, 2 years, and 5 years following ECMO initiation. We analyzed health system costs (in Canadian dollars) in the 1 year following the date of the index admission.Results: A total of 692 patients were included. Mean (standard deviation [SD]) age was 51.3 (16.0) years. Median (interquartile range [IQR]) time to ECMO initiation from date of admission was 2 (0-9) days. In-hospital mortality was 40.0%. Mortality at 1 year, 2 years, and 5 years was 45.1%, 49.0%, and 57.4%, respectively. Among survivors, 78.4% were discharged home, while 21.2% were discharged to continuing care. Median (IQR) total costs in the 1 year following admission among all patients were Canadian $130,157 (Canadian $58,645-Canadian $240,763), of which Canadian $91,192 (Canadian $38,507-Canadian $184,728) were attributed to inpatient care.Conclusions: Hospital mortality among critically ill adults receiving ECMO for advanced cardiopulmonary support is relatively high, but does not markedly increase in the years following discharge. Survivors are more likely to be discharged home than to continuing care. Median costs are high, but largely reflect inpatient hospital costs, and not costs incurred following discharge. [ABSTRACT FROM AUTHOR]

Purpose: We assessed feasibility and safety of extracorporeal carbon dioxide removal (ECCO2R) to facilitate ultra-protective ventilation (VT 4 mL/kg and PPLAT ≤ 25 cmH2O) in patients with moderate acute respiratory distress syndrome (ARDS).Methods: Prospective multicenter international phase 2 study. Primary endpoint was the proportion of patients achieving ultra-protective ventilation with PaCO2 not increasing more than 20% from baseline, and arterial pH > 7.30. Severe adverse events (SAE) and ECCO2R-related adverse events (ECCO2R-AE) were reported to an independent data and safety monitoring board. We used lower CO2 extraction and higher CO2 extraction devices (membrane lung cross-sectional area 0.59 vs. 1.30 m2; flow 300-500 mL/min vs. 800-1000 mL/min, respectively).Results: Ninety-five patients were enrolled. The proportion of patients who achieved ultra-protective settings by 8 h and 24 h was 78% (74 out of 95 patients; 95% confidence interval 68-89%) and 82% (78 out of 95 patients; 95% confidence interval 76-88%), respectively. ECCO2R was maintained for 5 [3-8] days. Six SAEs were reported; two of them were attributed to ECCO2R (brain hemorrhage and pneumothorax). ECCO2R-AEs were reported in 39% of the patients. A total of 69 patients (73%) were alive at day 28. Fifty-nine patients (62%) were alive at hospital discharge.Conclusions: Use of ECCO2R to facilitate ultra-protective ventilation was feasible. A randomized clinical trial is required to assess the overall benefits and harms. CLINICALTRIALS.GOV: NCT02282657. [ABSTRACT FROM AUTHOR]

BACKGROUND: The 2009 H1N1 influenza epidemic saw a rise in the use of extracorporeal membrane oxygenation (ECMO) as a supportive therapy for refractory ARDS. We sought to determine whether ECMO utilization follows a seasonal pattern that matches the influenza season, and whether it can further be explained by the incidence of each influenza subtype. METHODS: We performed a longitudinal analysis of non-cardiac and cardiac-associated ECMO cases from the National In-patient Sample from 2005 to 2014, using overdispersed Poisson regression to evaluate associations with influenza incidence categorized by influenza-like illness and total positive influenza tests divided by subtype from the Centers for Disease Control and Prevention. RESULTS: Non-cardiac ECMO use was positively associated with influenza-like illness incidence in the current month (incidence risk ratio [IRR] 1.11, 95% confidence interval [CI] 1.07-1.15, P < .001) and with influenza-like illness in the previous month (IRR 1.09, 95% CI 1.05-1.14, P < .001). The 2009 H1N1 subtype had the strongest association with non-cardiac ECMO (IRR 1.19, 95% CI 1.09 - 1.31, P < .001). Cardiac ECMO was also positively associated with the incidence of influenza-like illness (IRR 1.05, 95% CI 1.01-1.09, P = .02). CONCLUSION: Non-cardiac and cardiac ECMO use in the United States were significantly associated with influenza incidence. The influenza A, H1N1 2009, subtype had the strongest association. [ABSTRACT FROM AUTHOR]

Background: Acute respiratory distress syndrome (ARDS) has been shown to be frequently associated with haemodynamic instability requiring the use of vasopressors. To date, there is still some uncertainty in the use of veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) in haemodynamically unstable ARDS patients.Methods: We therefore assessed whether patients receiving pre ECMO vasopressors had a worse prognosis and, furthermore, we reviewed the factors associated with the use of pre ECMO vasopressors in 92 consecutive patients with refractory ARDS treated with VV-ECMO. All patients were submitted to an echocardiogram before implantation.Results: In our series, 55 patients (59.7%) were given a vasopressor. Septic shock is the main cause of vasopressor requirement (45.5%). When compared with patients without vasopressors, the subgroup under vasopressors showed a significantly higher sequential organ failure assessment (SOFA) score (p=0.040), a lower pH (p=0.013), lower pO2 values (p=0.030) and higher lactate levels (p=0.024). A higher incidence of right ventricular (RV) dysfunction and of biventricular dysfunction were observed in patients under vasopressors (p=0.018 and p=0.036, respectively). The intensive care unit (ICU) mortality rate was 43.4% (40/92) with no difference between the two subgroups.Conclusions: In refractory ARDS requiring VV-ECMO, infusion of vasopressors is needed in a high proportion of patients, who did not exhibit a worse prognosis when compared to haemodynamically stable patients. Pre ECMO echocardiography helps in characterising these patients since they showed a higher incidence of RV (and biventricular) dysfunction. According to our data, in ARDS patients refractory to conventional treatment, haemodynamic instability should not be considered a contraindication to VV-ECMO support. [ABSTRACT FROM AUTHOR]

Background Case series have reported favorable outcomes with extracorporeal membrane oxygenation (ECMO) in patients with severe acute respiratory distress syndrome. However, those patients were generally young, with few comorbid conditions. Objective To characterize the clinical features and survival rates of patients with severe acute respiratory distress syndrome who met criteria for ECMO but were managed without it. Methods Patients who met the study criteria were identified prospectively. Inclusion criteria for ECMO included severe hypoxemia, uncompensated hypercapnia, or elevated end-inspiratory plateau pressures despite low tidal volume ventilation. Predicted survival rates with ECMO were calculated using the Respiratory ECMO Survival Prediction score. Results Of the 46 patients who met the criteria for severe acute respiratory distress syndrome and ECMO consideration, 5 received ECMO and 16 patients had at least 1 contraindication to it. The remaining 25 patients met ECMO criteria but did not receive the treatment. The patients' mean age was 53.5 (SD, 14.3) years; 84% had at least 1 major comorbid condition. The median predicted survival rate with ECMO was 57%. The actual hospital discharge survival rate without ECMO was 56%. Conclusions The general medical intensive care patient population with severe acute respiratory distress syndrome is older and sicker than patients reported in prior case series in which patients were treated with ECMO. In this study, the survival rate without ECMO was similar to predicted survival rates with ECMO. [ABSTRACT FROM AUTHOR]

Rationale: Clinicians' current practice patterns in the management of acute respiratory distress syndrome (ARDS) and refractory hypoxemia are not well described.Objectives: To describe mechanical ventilation strategies and treatment adjuncts for adults with ARDS, including refractory hypoxemia.Methods: This was a prospective cohort study (March 2014-February 2015) of mechanically ventilated adults with moderate-to-severe ARDS requiring an FiO2 of 0.50 or greater in 24 intensive care units.Results: We enrolled 664 patients: 222 (33%) with moderate and 442 (67%) with severe ARDS. On Study Day 1, mean Vt was 7.5 (SD = 2.1) ml/kg predicted body weight (n = 625); 80% (n = 501) received Vt greater than 6 ml/kg. Mean positive end-expiratory pressure (PEEP) was 10.5 (3.7) cm H2O (n = 653); 568 patients (87%) received PEEP less than 15 cm H2O. Treatment adjuncts were common (n = 440, 66%): neuromuscular blockers (n = 276, 42%), pulmonary vasodilators (n = 118, 18%), prone positioning (n = 67, 10%), extracorporeal life support (n = 29, 4%), and high-frequency oscillatory ventilation (n = 29, 4%). Refractory hypoxemia, defined as PaO2 less than 60 mm Hg on FiO2 of 1.0, occurred in 138 (21%) patients. At onset of refractory hypoxemia, mean Vt was 7.1 (SD = 2.0) ml/kg (n = 124); 95 patients (77%) received Vt greater than 6 ml/kg. Mean PEEP was 12.1 (SD = 4.4) cm H2O (n = 133); 99 patients (74%) received PEEP less than 15 cm H2O. Among patients with refractory hypoxemia, 91% received treatment adjuncts (126/138), with increased use of neuromuscular blockers (n = 87, 63%), pulmonary vasodilators (n = 57, 41%), and prone positioning (n = 32, 23%).Conclusions: Patients with moderate-to-severe ARDS receive treatment adjuncts frequently, especially with refractory hypoxemia. Paradoxically, therapies with less evidence supporting their use (e.g., pulmonary vasodilators) were over-used, whereas those with more evidence (e.g., prone positioning, neuromuscular blockade) were under-used. Patients received higher Vts and lower PEEP than would be suggested by the evidence. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to concisely describe the current standards of care, major recent advances, common beliefs that have been contradicted by recent trials, areas of uncertainty, and clinical studies that need to be performed over the next decade and their expected outcomes with regard to extracorporeal membrane oxygenation (ECMO).Methods: Narrative review based on a systematic analysis of the medical literature, national and international guidelines, and expert opinion.Results: The use of venovenous ECMO (VV-ECMO) is increasing in the most severe forms of acute lung injury. In patients with cardiogenic shock, short-term veno-arterial ECMO (VA-ECMO) provides both pulmonary and circulatory support. Technological improvements and recently published studies suggest that ECMO is able to improve patients' outcomes. There are, however, many uncertainties regarding the real benefits of this technique both in hemodynamic and respiratory failure, the territorial organization to deliver ECMO, the indications and the use of concomitant treatments.Conclusions: Although there have been considerable advances regarding the use of ECMO in critically ill patients, the risk/benefit ratio remains underinvestigated. ECMO indications, organization of ECMO delivery, and use of adjuvant therapeutics need also to be explored. Ongoing and future studies may be able to resolve these issues. [ABSTRACT FROM AUTHOR]

Objectives: Over the last decade, extracorporeal membrane oxygenation (ECMO) has become a promising option for patients with severe acute respiratory distress syndrome (ARDS). In this single-center observational cohort study, data from a patient group with severe ARDS treated with ECMO was analyzed. Methods: Data from 46 patients [median age 54 years (18 to 72), male: 65.2%] were evaluated retrospectively between January 2009 and September 2015. Results: Diagnosis leading to ARDS was pneumonia in 63.1% of the patients. The median SOFA Score was 13 (10 to 19) and the median LIS was 3.5 (2.67 to 4). The median duration of ECMO support was 12 days (1 to 86). Twenty-eight patients (60.9%) were successfully weaned from ECMO and 22 patients survived (47.8%). Non-survivors needed significantly more frequent renal replacement therapy (37.5% vs. 18.2%; p<0.01) and transfusion of red blood cell concentrates [0.4 units (0.3 to 1.2) vs. 0.9 units (0.5 to 1.6); p<0.01] during ECMO support compared to patients who survived. Conclusion: This report suggests that ECMO currently allows treatment of severe ARDS with presumed improved survival. The incidence rate of acute kidney injury and transfusion are associated with adverse outcomes. [ABSTRACT FROM AUTHOR]

Rationale: Adoption and de-adoption of adjuvant strategies to mechanical ventilation for acute respiratory failure (ARF), and factors associated with their selection, have not been extensively evaluated.Objectives: To evaluate change in use of adjuvants to mechanical ventilation for ARF (2008-2013), the impact of landmark publications on adoption and de-adoption, and factors associated with use.Methods: Changes in use of four adjuvants for ARF from 2008 to 2013, the impact of landmark publications on use, and factors associated with use were evaluated with the Premier Database. Extracorporeal membrane oxygenation (ECMO), inhaled nitric oxide, inhaled epoprostenol, and continuous neuromuscular blockading agents (cNMBAs) in adult mechanically ventilated patients were identified on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification codes and billing data.Measurements and Main Results: Among 514,913 patients with ARF, 11,567 (2.3%) were treated with at least one adjuvant. cNMBAs were the most frequently used adjuvants (n = 10,073, 2.1% in capable hospitals), followed by inhaled pulmonary vasodilators (n = 1,878, 1.0% in capable hospitals; 58% nitric oxide), and ECMO (n = 195, 0.2% in capable hospitals). There was an increase in ECMO and inhaled epoprostenol over time but no change in nitric oxide or cNMBAs. Segmented regression analysis was used to evaluate whether clinical practice was in accordance with emerging evidence from landmark studies. Using the relevant landmark publication dates, these analyses did not reveal any change in use over time after publication with the exception of inhaled epoprostenol-for which rates of growth decreased over time, possibly in response to the evidence. There was a significant amount of variability in patient and hospital factors associated with use with between adjuvants.Conclusions: Between 2008 and 2013, there was an increase in use of ECMO and inhaled epoprostenol, and no change in use of inhaled nitric oxide or continuous intravenous infusion of a neuromuscular blocking agent. There was considerable variability in patient and hospital factors associated with use across different adjuvants. [ABSTRACT FROM AUTHOR]

Background: The amount of extracorporeal carbon dioxide removal may influence respiratory drive in acute respiratory distress syndrome (ARDS) patients undergoing extracorporeal membrane oxygenation (ECMO). The authors evaluated the effects of different levels of extracorporeal carbon dioxide removal in patients recovering from severe ARDS undergoing pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA).Methods: The authors conducted a prospective, randomized, crossover study on eight spontaneously breathing ARDS patients undergoing venovenous ECMO since 28 ± 20 days. To modulate carbon dioxide extraction, ECMO gas flow (GF) was decreased from baseline resting protective conditions (i.e., GF100%, set to obtain pressure generated in the first 100 ms of inspiration against an occluded airway less than 2 cm H2O, respiratory rate less than or equal to 25 bpm, tidal volume less than 6 ml/kg, and peak airway pressure less than 25 cm H2O) to GF50%-GF25%-GF0% during both PSV and NAVA (random order for ventilation mode). Continuous recordings of airway pressure and flow and esophageal pressure were obtained and analyzed during all study phases.Results: At higher levels of extracorporeal carbon dioxide extraction, pressure generated in the first 100 ms of inspiration against an occluded airway decreased from 2.8 ± 2.7 cm H2O (PSV, GF0%) and 3.0 ± 2.1 cm H2O (NAVA, GF0%) to 0.9 ± 0.5 cm H2O (PSV, GF100%) and 1.0 ± 0.8 cm H2O (NAVA, GF100%; P < 0.001) and patients' inspiratory muscle pressure passed from 8.5 ± 6.3 and 6.5 ± 5.5 cm H2O to 4.5 ± 3.1 and 4.2 ± 3.7 cm H2O (P < 0.001). In time, decreased inspiratory drive and effort determined by higher carbon dioxide extraction led to reduction of tidal volume from 6.6 ± 0.9 and 7.5 ± 1.2 ml/kg to 4.9 ± 0.8 and 5.3 ± 1.3 ml/kg (P < 0.001) and of peak airway pressure from 21 ± 3 and 25 ± 4 cm H2O to 21 ± 3 and 21 ± 5 cm H2O (P < 0.001). Finally, transpulmonary pressure linearly decreased when the amount of carbon dioxide extracted by ECMO increased (R = 0.823, P < 0.001).Conclusions: In patients recovering from ARDS undergoing ECMO, the amount of carbon dioxide removed by the artificial lung may influence spontaneous breathing. The effects of carbon dioxide removal on spontaneous breathing during the earlier acute phases of ARDS remain to be elucidated. [ABSTRACT FROM AUTHOR]

Objective: Extracorporeal membrane oxygenation is a rescue therapy for patients with severe lung failure. Major complications caused by extracorporeal membrane oxygenation are bleeding, thrombosis, and hemolysis. The aim of this study was to compare the impact of different extracorporeal membrane oxygenation systems on blood hemostasis in adults during veno-venous extracorporeal membrane oxygenation therapy.Design: Single center prospective randomized study.Setting: University Hospital Regensburg, Germany.Patients: Adult patients with severe acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation therapy.Interventions: None.Measurements and Main Results: Three different extracorporeal membrane oxygenation systems: the Cardiohelp system (Maquet Cardiopulmonary AG), the Dideco ECC.O5 (Sorin Group), and the Deltastream system with Hilite 7000 LT + DP3 pumphead (Medos Medizintechnik AG) were compared. Therefore hemostasis, anticoagulation, hemolysis, and inflammatory parameters were monitored. Of the 54 patients included in the study, 18 patients each were randomly assigned to the three different extracorporeal membrane oxygenation systems. Exclusion criteria were acute renal failure, trauma, and surgery within 2 days. The median time on veno-venous extracorporeal membrane oxygenation support was 13.5 days (4-70 d). Median platelet count had dropped from 220.5 G/L before extracorporeal membrane oxygenation therapy to a minimum of 133 G/L by the last day of extracorporeal membrane oxygenation support. During the first 5 days of extracorporeal membrane oxygenation therapy, prothrombin fragment 1.2 (F1.2) (1.36-2.4 µM), thrombin-antithrombin complex (14.5-50 µg/L), and D-dimers (6.00-27.0 mg/L) increased, whereas fibrinogen values dropped from 5.8 to 4.1 g/L. The three different extracorporeal membrane oxygenation systems did not show any differences with regard to hemostasis, anticoagulation, hemolysis, and inflammatory parameters within the first 5 days of extracorporeal membrane oxygenation therapy.Conclusions: Over time, miniaturized veno-venous extracorporeal membrane oxygenation therapy increasingly activates coagulation. The different types of membrane oxygenators and pumps did not significantly alter hemostasis. [ABSTRACT FROM AUTHOR]

Objective: To assess the safety and efficacy of combining extracorporeal CO2 removal with continuous renal replacement therapy in patients presenting with acute respiratory distress syndrome and acute kidney injury.Design: Prospective human observational study.Settings: Patients received volume-controlled mechanical ventilation according to the acute respiratory distress syndrome net protocol. Continuous venovenous hemofiltration therapy was titrated to maintain maximum blood flow and an effluent flow of 45 mL/kg/h with 33% predilution.Patients: Eleven patients presenting with both acute respiratory distress syndrome and acute kidney injury required renal replacement therapy.Interventions: A membrane oxygenator (0.65 m) was inserted within the hemofiltration circuit, either upstream (n = 7) or downstream (n = 5) of the hemofilter. Baseline corresponded to tidal volume 6 mL/kg of predicted body weight without extracorporeal CO2 removal. The primary endpoint was 20% reduction in PaCO2 at 20 minutes after extracorporeal CO2 removal initiation. Tidal volume was subsequently reduced to 4 mL/kg for the remaining 72 hours.Measurements and Main Results: Twelve combined therapies were conducted in the 11 patients. Age was 70 ± 9 years, Simplified Acute Physiology Score II was 69 ± 13, Sequential Organ Failure Assessment score was 14 ± 4, lung injury score was 3 ± 0.5, and PaO2/FIO2 was 135 ± 41. Adding extracorporeal CO2 removal at tidal volume 6 mL/kg decreased PaCO2 by 21% (95% CI, 17-25%), from 47 ± 11 to 37 ± 8 Torr (p < 0.001). Lowering tidal volume to 4 mL/kg reduced minute ventilation from 7.8 ± 1.5 to 5.2 ± 1.1 L/min and plateau pressure from 25 ± 4 to 21 ± 3 cm H2O and raised PaCO2 from 37 ± 8 to 48 ± 10 Torr (all p < 0.001). On an average of both positions, the oxygenator's blood flow was 410 ± 30 mL/min and the CO2 removal rate was 83 ± 20 mL/min. The oxygenator blood flow (p <0.001) and the CO2 removal rate (p = 0.083) were higher when the membrane oxygenator was placed upstream of the hemofilter. There was no safety concern.Conclusions: Combining extracorporeal CO2 removal and continuous venovenous hemofiltration in patients with acute respiratory distress syndrome and acute kidney injury is safe and allows efficient blood purification together with enhanced lung protective ventilation. [ABSTRACT FROM AUTHOR]

Objective: This study aims to identify morphological changes in the lung parenchyma of acute respiratory distress syndrome (ARDS) survivors after extracorporeal membrane oxygenation (ECMO) by high-resolution computed tomography (HRCT) follow-up. Factors influencing these changes are also examined. Methods: Information and lung HRCT scans were collected and studied 1, 3, 6, and 12 months after the withdrawal of severe ARDS survivors rescued by ECMO in the Respiratory Care Unit of Beijing Chaoyang Hospital from November 2009 to August 2012. The observation endpoint was set as the time when the lung lesions were basically absorbed or 12 months after withdrawal. Results: Among nine survivors, one survivor was lost to follow-up. The lesions of two patients, which were attributed to bacterial pneumonia and pneumocystis pneumonia, were basically absorbed 1 month after surgery. Six patients completed the 12 month follow-up. Although initial morphological changes varied, different degrees of absorption improvement were observed in later stages of treatment. Lung HRCT analysis on the sixth month indicated that the degree of involvement of the ventral region was greater than that of the dorsal area. No significant difference was observed in patients in terms of ECMO support time, pre-ECMO Murray score, and APACHE II score, among others. Conclusion: Lung HRCT of severe ARDS survivors after ECMO treatment showed various degrees of morphological changes in the lung parenchyma. The severity of these changes may be associated with the disease duration. [ABSTRACT FROM AUTHOR]

Background: Over the last decade, technical improvements in extracorporeal membrane oxygenation (ECMO) equipment have reduced procedure-related complications and have made ECMO an effective option for patients with acute respiratory distress syndrome (ARDS) if conventional therapy fails.Methods: In this report, we present our early experience with the Cardiohelp, a new portable miniaturized ECMO system, in 22 consecutive patients with ARDS. All patients were placed on venovenous ECMO. Cannulas were inserted percutaneously, employing the Seldinger technique. Data were collected prospectively.Results: The median patient age was 47 years (36 to 61). Fifteen patients from regional hospitals were too unstable for conventional transport and were placed on Cardiohelp at the referring hospital and then transported to our institution. The patients were transported by ambulance (n=2) or helicopter (n=13) over a distance of 50-250 km. Cardiohelp support resulted in immediate improvement of gas exchange and highly protective ventilation. The median duration of support was 13 days (8 to 19). An exchange of the device was necessary in 9 patients. Sixteen patients (72.7%) were successfully weaned from ECMO and fifteen patients (68.2%) survived. Device-related complications were not observed.Conclusions: The compact portable ECMO device Cardiohelp is a highly effective method to secure vital gas exchange and to reduce further ventilator-induced lung injury in patients with acute respiratory failure. Crucial technical innovations and ease of device transport and implantation allow location-independent stabilization with consecutive inter-hospital transfer. [ABSTRACT FROM AUTHOR]

The article presents a study on the use of passive leg raising (PLR) to predict fluid responsiveness in acute respiratory distress syndrome (ARDS) patients who were treated with venovenous extracorporeal membrane oxygenation (ECMO). The study uses a prospective study conducted in a university hospital surgical intensive care units (ICU). Results show that PLR significantly increased stroke volume (SV), cardiac output, and pump flow.

Objective: To evaluate the effect of extracorporeal gas exchange (ECMO) on mortality of patients referred with severe acute respiratory distress syndrome (ARDS).Design and Setting: Prospective observational study in a university hospital ICU.Patients: 150 patients with severe ARDS.Interventions: Multimodal treatment with and without ECMO.Measurements and Main Results: We treated 118 patients (78.7%) conservatively and 32 patients with ECMO. Patients in the ECMO group presented with significantly more severe disease (lung injury score 3.8+/-0.3 vs. 3.3+/-0.4; SOFA score 52+/-14 vs. 43+/-12; and SAPS score 14+/-3.3 vs. 10+/-3.5). Mortality in ECMO-treated patients tended to be higher than that with conservative treatment (46.9% vs. 28.8%, p=0.059). Multivariate logistic regression analyses with backward selection excluded ECMO as predictor of mortality (p=0.79). Independent predictors of mortality were age (odds ratio 1.044, 95% confidence interval 1.014-1.075, p=0.004), mean pulmonary artery pressure (1.082, 1.026-1.141, p=0.036), sequential organ failure assessment score (1.148, 1.018-1.294, p=0.024), and days of mechanical ventilation prior to referral (1.064, 1.008-1.123, p=0.025).Conclusion: ECMO treatment does not predict mortality in patients with most severe ARDS. [ABSTRACT FROM AUTHOR]

Subject: Mortality rates remain high for the acute respiratory distress syndrome (ARDS) despite standardised treatment algorithms. Little is known about prognostic factors and exclusion criteria for advanced treatment including extracorporeal membrane oxygenation (ECMO).Methods: In an observational study design a cohort of 93 patients with severe ARDS admitted to a referral centre were analysed according to ventilatory and vital parameters.Results: Overall survival rate was 70% and in patients who received ECMO treatment it was 67%. In patients exhibiting relevant co-morbidity the odds ratio for fatal outcome increased to 4.7 (95% CI: 3.3-24.9), and patients with multiple organ failure had a 7.5-fold increase (95% CI: 2.3-25.2) for risk of death. Survivors demonstrated a more pronounced improvement in oxygenation ( p<0.05) and CO(2) removal ( p<0.05) than non-survivors.Conclusions: Advanced treatment of ARDS including ECMO represents a therapeutic option if none of the currently considered contraindications are present. An improvement in gas exchange parameters, but not a defined value per se may be useful as a prognostic factor for favourable outcome. [ABSTRACT FROM AUTHOR]

Background: Extra Corporeal Membrane Oxygenation (ECMO) has become an accepted treatment option for severely ill patients. Due to a limited availability of ECMO support therapy, patients must often be transported to a specialised centre before or after cannulation. According to the ELSO guidelines, an ECMO specialist should be present for such interventions. Here we describe the safety and efficacy of a reduced team approach involving one anaesthesiologist, experienced in specialised intensive care medicine, and a specialised critical care nurse. Methods: This study is a 10 years retrospective, single institution analysis of all data collected between January 2007 and December 2016 from the medical records at the University Hospital Bonn, Germany. Results: The Bonner mobile ECMO team was deployed in 170 cases for on-site evaluation for ECMO support therapy. 4 (2.4%) patients died prior to arrival or during the implementation of ECMO support. Of the remaining 166 patients, 126 were cannulated at the referring site, 40 were transported without ECMO. Of those, 21 were subsequently cannulated out our centre. 19 patients never received ECMO treatment. The primary indication for ECMO treatment was ARDS (159/166 patients). Veno-venous ECMO was initiated in 137, whilst 10 patients received veno-arterial ECMO treatment. Mean transportation time was 75 ± 36 min, and mean transport distance was 56 ± 57 km. In total, 26 complications were observed, three being directly transport-related. The overall survival was 55%. Conclusions: Initiation of extracorporeal membrane oxygenation and subsequent transport can be safely and efficiently performed by a two-man team with good outcome. [ABSTRACT FROM AUTHOR]

Background: Although many risk models have been tested in patients who undergo extracorporeal membrane oxygenation, few have been assessed for patients who received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support in the emergency department (ED). This study aimed to successfully predict outcomes of patients with cardiac or noncardiac failure who received VA-ECMO in the ED within 24 hours of arrival at the ED.Method: This retrospective, observational cohort study included 154 patients, who were classified as cardiac (n = 127) and noncardiac (n = 27) patients and received VA-ECMO within 24 hours after arrival at the China Medical University Hospital ED in Taiwan between January 2009 and September 2014. We recorded mechanical ventilation settings, arterial blood gases, laboratory parameters including plasma lactate level, requirement of catecholamines, and risk scores at time of ECMO initiation. ECMO and mechanical ventilation support duration, length of stay in the hospital, and 90-day mortality data were also examined.Results: The overall mortality rate was 64.9 %. We used "survival after veno-arterial ECMO (SAVE)" scores to assess survival prediction in survival and nonsurvival groups, which was statistically different (-3.2 vs. -8.3, p <0.001). According to multivariate Cox proportional regression of survival, lactate (hazard ratio [HR] = 1.01, 95 % confidence interval [CI], 1.01-1.01, p <0.001) and SAVE score (HR = 0.92, [95 % CI, 0.88-0.96], p = 0.001) were independent predictors of outcome. Excellent discrimination (area under curve (AUC) = 0.843) was observed when lactate and SAVE score were combined, which we referred to as "the modified SAVE score."Conclusions: Modified SAVE scores improved outcome prediction for patients who underwent urgent VA-ECMO in the ED. [ABSTRACT FROM AUTHOR]