Chest
Volume 152, Issue 3, September 2017, Pages 639-649
Journal home page for Chest

Contemporary Reviews in Critical Care Medicine
Extracorporeal Membrane Oxygenation for Adult Respiratory Failure: 2017 Update

https://doi.org/10.1016/j.chest.2017.06.016Get rights and content

The use of extracorporeal membrane oxygenation (ECMO) for respiratory failure in adults is growing rapidly, driven in large part by advances in technology, which have made ECMO devices easier to implement and safer and more efficient. Accompanying this increase in use is a nearly exponential increase in ECMO-related literature. However, the great majority of the literature is composed of retrospective observational data, often in the form of single-center studies with relatively small numbers of subjects. The overall lack of high-quality data, including prospective randomized trials, makes it difficult to justify the rate at which ECMO use is increasing and calls attention to the need for more rigorously designed studies. Nonetheless, given its ability to support patients with severe gas exchange impairment and the potential for it to minimize the deleterious effects of invasive mechanical ventilation, there appears to be a legitimate role for ECMO in severe respiratory failure in adults.

Section snippets

Physiology of ECMO

ECMO refers to a circuit that directly oxygenates and removes carbon dioxide from blood through an extracorporeal gas exchange device, commonly referred to as a membrane oxygenator (Fig 1).6 The oxygenator consists of a semipermeable membrane that separates a blood compartment from a gas compartment, allowing only gas molecules to diffuse between compartments. At the time of ECMO initiation, catheters (or cannulas) are placed with their drainage and reinfusion ports located in central vessels.

ECMO Configurations

Venovenous ECMO traditionally involves cannulation at two distinct venous access points, one for drainage of deoxygenated blood and one for reinfusion of oxygenated blood (Fig 2). Drawbacks to two-site venovenous ECMO include the need for femoral access and the potential for excess recirculation when the drainage and reinfusion ports are in close proximity. Newer cannula designs include cannulas with two lumens so that a single cannula inserted typically into an internal jugular vein can

ARDS

The most common indication for ECMO in respiratory failure is severe ARDS, which is defined by the presence of bilateral infiltrates on chest imaging within 7 days of an inciting event and impaired oxygenation (Pao2/Fio2 ratio < 100 mm Hg while receiving positive-pressure ventilation), which is not fully explained by cardiogenic pulmonary edema.20 The standard of care for invasive mechanical ventilation in ARDS is a volume- and pressure-limited ventilation strategy, which improves survival, in

Contraindications to ECMO for Respiratory Failure

When considering ECMO for severe respiratory failure, one must consider the likelihood of recovery when the underlying process is thought to be reversible and the potential candidacy for transplantation when the respiratory failure is deemed to be irreversible. Relative contraindications to ECMO in acute respiratory failure include the prolonged use of high-pressure ventilation or high Fio2, limited vascular access, contraindications to the use of anticoagulation, and the presence of any

Anticoagulation

Continuous systemic anticoagulation is generally needed to maintain ECMO circuit patency and minimize the risk of thrombosis in both the circuit and the patient. However, anticoagulation goals must balance thrombotic risk with potential hemorrhagic complications. There are currently no universally accepted anticoagulation goals for ECMO nor is there a consensus on how anticoagulation should be monitored. Activated clotting time, activated partial thromboplastin time, and thromboelastography,

Complications

Complications must always be considered whenever a novel therapy is being introduced, especially one as invasive as ECMO. Hemorrhage remains among the most commonly cited complications, although the rates of bleeding and their severity vary widely by center and anticoagulation practices.76 Thrombosis, either within the circuit or related to the indwelling portions of the cannulas, poses an embolic risk to the patient. Other hematologic complications associated with ECMO include hemolysis,

Economic Impact

There is a paucity of data on the economic impact of ECMO, with costs varying widely by health system, choice of device components, duration of support, management strategies, and staffing models.26, 81 In the CESAR trial, the average total costs per patient were £73,979 vs £33,435, respectively (cost of ECMO per quality-adjusted life year, £19,252), which may be explained in part by increased ICU and hospital lengths of stay.26 As ECMO is studied further, cost-benefit analyses will be a

Ethical Considerations

ECMO for advanced respiratory failure has the potential to create ethical dilemmas much in the same way as any life-sustaining intervention (ie, in whom should it be started and if and when should it be withdrawn). However, the lack of an extracorporeal destination device for respiratory failure creates the potential for a particularly difficult situation in which a patient supported with ECMO with the intention of either recovery or transplantation is no longer able to achieve either, a

Future Directions

ECMO can provide support for patients with advanced respiratory failure only as a bridge to recovery or lung transplantation, as no destination device currently exists for respiratory failure, ie, the equivalent of a ventricular assist device in heart failure. As ECMO technology improves, including smaller more durable circuits with increasingly efficient membrane oxygenators, the field is moving toward a portable extracorporeal gas exchange device, effectively an artificial lung. Such a device

Conclusions

ECMO is capable of supporting severe derangements in gas exchange in both acute and chronic respiratory failure, with data showing potential for improving survival in patients with high rates of morbidity and mortality. Its use should remain in centers sufficiently experienced with the technology, and additional research is needed before ECMO can be recommended for more widespread application.

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following: D. B. is currently on the medical advisory boards of ALung Technologies and Kadence. All compensation for these activities is paid to Columbia University. None declared (D. A.).

References (83)

  • D. Weill et al.

    A consensus document for the selection of lung transplant candidates: 2014—an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation

    J Heart Lung Transplant

    (2015)
  • E. Sy et al.

    Anticoagulation practices and the prevalence of major bleeding, thromboembolic events, and mortality in venoarterial extracorporeal membrane oxygenation: a systematic review and meta-analysis

    J Crit Care

    (2017)
  • C.L. Agerstrand et al.

    Blood conservation in extracorporeal membrane oxygenation for acute respiratory distress syndrome

    Ann Thorac Surg

    (2015)
  • D. Glick et al.

    Clinically suspected heparin-induced thrombocytopenia during extracorporeal membrane oxygenation

    J Crit Care

    (2015)
  • W.D. Schweickert et al.

    Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial

    Lancet

    (2009)
  • M.L. Paden et al.

    ELSO Registry. Update and outcomes in extracorporeal life support

    Semin Perinatol

    (2014)
  • S.M. Johnson et al.

    Increased risk of cardiovascular perforation during ECMO with a bicaval, wire-reinforced cannula

    J Pediatr Surg

    (2014)
  • D.C. Abrams et al.

    Ethical dilemmas encountered with the use of extracorporeal membrane oxygenation in adults

    Chest

    (2014)
  • W.M. Zapol et al.

    Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study

    JAMA

    (1979)
  • A.H. Morris et al.

    Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome

    Am J Respir Crit Care Med

    (1994)
  • E. Fan et al.

    Venovenous extracorporeal membrane oxygenation for acute respiratory failure: a clinical review from an international group of experts

    Intensive Care Med

    (2016)
  • D. Abrams et al.

    What is new in extracorporeal membrane oxygenation for ARDS in adults?

    Intensive Care Med

    (2013)
  • C. Karagiannidis et al.

    Extracorporeal membrane oxygenation: evolving epidemiology and mortality

    Intensive Care Med

    (2016)
  • D. Brodie et al.

    Extracorporeal membrane oxygenation for ARDS in adults

    N Engl J Med

    (2011)
  • M. Schmidt et al.

    Blood oxygenation and decarboxylation determinants during venovenous ECMO for respiratory failure in adults

    Intensive Care Med

    (2013)
  • D. Abrams et al.

    Recirculation in venovenous extracorporeal membrane oxygenation

    ASAIO J

    (2015)
  • M.C. Sklar et al.

    Extracorporeal carbon dioxide removal in patients with chronic obstructive pulmonary disease: a systematic review

    Intensive Care Med

    (2015)
  • M. Fitzgerald et al.

    Extracorporeal carbon dioxide removal for patients with acute respiratory failure secondary to the acute respiratory distress syndrome: a systematic review

    Crit Care

    (2014)
  • D. Wang et al.

    Wang-Zwische double lumen cannula-toward a percutaneous and ambulatory paracorporeal artificial lung

    ASAIO J

    (2008)
  • J. Javidfar et al.

    Use of bicaval dual-lumen catheter for adult venovenous extracorporeal membrane oxygenation

    Ann Thorac Surg

    (2011)
  • D. Abrams et al.

    Insertion of bicaval dual-lumen cannula via the left internal jugular vein for extracorporeal membrane oxygenation

    ASAIO J

    (2012)
  • J. Javidfar et al.

    Insertion of bicaval dual lumen extracorporeal membrane oxygenation catheter with image guidance

    ASAIO J

    (2011)
  • M. Biscotti et al.

    Hybrid configurations via percutaneous access for extracorporeal membrane oxygenation: a single-center experience

    ASAIO J

    (2014)
  • J. Javidfar et al.

    Subclavian artery cannulation for venoarterial extracorporeal membrane oxygenation

    ASAIO J

    (2012)
  • Chicotka S, Rosenzweig EB, Brodie D, Bacchetta M. The “central sport model”: extracorporeal membrane oxygenation using...
  • V.M. Ranieri et al.

    Acute respiratory distress syndrome: the Berlin Definition

    JAMA

    (2012)
  • Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network

    N Engl J Med

    (2000)
  • A. Mercat et al.

    Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial

    JAMA

    (2008)
  • E. Fan et al.

    An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome

    Am J Respir Crit Care Med

    (2017)
  • L. Papazian et al.

    Neuromuscular blockers in early acute respiratory distress syndrome

    N Engl J Med

    (2010)
  • C. Guerin et al.

    Prone positioning in severe acute respiratory distress syndrome

    N Engl J Med

    (2013)
  • Cited by (61)

    • Update on Mechanical Circulatory Support

      2023, Anesthesiology Clinics
    • Rehabilitation of adult patients on extracorporeal membrane oxygenation: A scoping review

      2022, Australian Critical Care
      Citation Excerpt :

      Extracorporeal membrane oxygenation (ECMO) is an advanced temporary form of mechanical life support used in patients with severe respiratory and/or cardiac failure.1,2

    • Pulmonary protection and management during extracorporeal membrane oxygenation

      2022, Cardiopulmonary Bypass: Advances in Extracorporeal Life Support
    • Extracorporeal Ventilatory Therapies

      2021, Cohen's Comprehensive Thoracic Anesthesia
    • How I Select Which Patients With ARDS Should Be Treated With Venovenous Extracorporeal Membrane Oxygenation

      2020, Chest
      Citation Excerpt :

      The Extracorporeal Life Support Organization guidelines23 also state that there are no absolute contraindications to ECMO. However, expert opinion5,28,29 would consider ECMO to be contraindicated in patients with severe irreversible respiratory disease if lung transplant is not an option, or in patients with irreversible conditions unlikely to benefit from ECMO (eg, catastrophic neurologic injuries, untreatable metastatic cancer). The effect of age on mortality related to VV-ECMO has been investigated in multiple trials, but no absolute cutoff has been determined.30-32

    View all citing articles on Scopus
    View full text