Acute respiratory failure is a difficult disease, in part, because it requires immediate decisions every time. Recently, extracorporeal membrane oxygenation (ECMO) has expanded beyond its established application for supportive management of acute respiratory failure.1 Hence, ECMO could be bridge therapy to lung transplantation or native lung recovery.2 However, there could be a case in which a patient is ineligible or does not desire lung transplantation, after the application of ECMO in acute respiratory failure. We report an experience with some ethical issues.
A 53 year old man visited the emergency room complaining about shortness of breath for 4 days. He was previously healthy but after smoke inhalation while burning some papers, he felt chest discomfort and febrile sensation. He visited the local hospital and chest radiographs and chest computed tomography revealed increased opacity throughout both lungs, thereby suggesting an atypical pneumonia or acute progression of idiopathic interstitial pneumonia. Despite treatments with empirical antibiotics and steroid at high dose, there was no improvement and he was referred to Samsung Medical Center. On arrival, the oxygen saturation was 77% although 15 L per minute oxygen via oxygen mask was supplied. Because repeated chest radiograph revealed aggravated state (Figure 1A), we initiated mechanical ventilator support and performed bronchoalveolar lavage (BAL) with transbronchial lung biopsy (TBLB). There was no evidence of infection in the BAL analysis, whereas the TBLB suggested acute lung injury in the exudative phase. For a detailed diagnosis of acute lung injury, video-assisted thoracoscopic surgery was performed for a lung biopsy. After the operation, because of worsening respiratory distress, we decided to start veno-venous ECMO (VV ECMO). The lung biopsy revealed diffuse interstitial and intraalveolar fibroblastic proliferations suggesting acute and subacute lung damage (Figure 2). After a pathology review, reversibility was expected with ECMO maintenance. Considering his alert mentality and both lung pneumothoraces, extubation was performed on ECMO day 3. Then, the patient was supplied with 3 L per minute of oxygen via nasal prong while fully awake. He was alert and conversant with his family, and started intermittent physical rehabilitation with limitations.
Initially, we expected ECMO weaning with improved lung function, but after 4 weeks, the ECMO removal was not yet foreseeable because of progressive bilateral pneumothoraces and no response to empirical treatment (Figure 1B). Hence, a lung transplantation option was suggested, but the patient strongly refused because of costs and personal problems. We discussed various issues with the hospital ethics committee, such as how long should we have to maintain the applied ECMO, and received written permission for a “do not resuscitate” (DNR) order and determined that there would be no more changes of the oxygenator. Thenceforth, the ECMO management was prolonged with no more changes of the oxygenator. About 9 weeks later, subsequent chest radiographs showed improvement on ECMO day 95 (Figure 1C). The ECMO weaning was considered, and achieved on ECMO day 104 with a tracheostomy. The total ECMO run time was 2,492 hours. Three weeks later, the patient was weaned off the ventilator and transferred to a local hospital for rehabilitation (Figure 1D).
During the maintenance of the awakening ECMO for 104 days, the oxygenator was changed three times and the patient had several complications, including popliteal artery occlusion because of thrombus, pneumothoraces, sepsis owing to urinary tract infection, duodenal ulcer bleeding, and transient encephalopathy because of suspicious embolic stroke, but there was no additional intubation (Figure 3).
Currently, ECMO is being used widely in severe forms of respiratory failure.1,2 Furthermore, as ECMO management is improving more and more, the maintenance duration is longer. For example, the mean time of extracorporeal life support (ECLS) was 177 hours and the longest adult respiratory ECLS run was 5,014 hours, according to the 2012 Extracorporeal Life Support Organization registry report.3
The benefit of applying ECMO is not only rescue from severe hypoxia but also a possibility to reduce ventilator-induced lung injury.1 Maintenance of awakening ECMO with extubation also contribute to native lung recovery.4 In addition, long-run maintenance brings about a greater chance of recovery for an injured lung. Hence, those procedures enhance the regeneration of the capacity of the native lung but the current consensuses have designated irreversibility within 3–4 weeks of duration for VV ECMO.2,5 Several cases have reported that the injured lung recovered with maintenance of the VV ECMO after more than 4 weeks in acute respiratory failure.2,6,7 The patient in this study took about 14 weeks for recovery. Considering those cases, timing for determining irreversible respiratory failure and lung transplantation could be delayed. It needs more discussion on a case-by-case basis.
As maintenance of the ECMO was prolonged, ethical dilemmas also developed. In this case, the patient did not want a lung transplantation although he could not be weaned from the applied ECMO. Hence, an ethical issue arose, such as to what extent should the ECMO be maintained. The patient knew there was no viable alternative at that time, except lung transplantation, so it was decided that there would be no change of the oxygenator. Recently, Ramanathan et al.8 proposed recommendations for ethical practice in 2015. They proposed considerations to stop ECMO when irreversibility is predicted without destination mechanical assist devices or transplantation; however, the maintenance duration could vary widely. Moreover, it was also emphasized that it is important that a patient’s family understands the futility on ECMO. Nevertheless, in practice, carrying out the recommendations will be a challenge just about every time.
In this case, the VV ECMO was maintained for 104 days and successful weaning was achieved with native lung recovery. However, considering the enhancement of the regenerative capacity of the lung, we still do not really know exactly what irreversible injury is and how long one has to wait for recovery; furthermore, these questions have concomitant ethical concerns, such as determining futility or maintenance of the ECMO. Needless to say, there will be more cases like the one in this case study with various differing concerns. Thus, there will have to be more discussion about the timing of determining futility and the ethical issues to applying the ECMO in acute respiratory failure.
1. Agerstrand CL, Bacchetta MD, Brodie D. ECMO for adult respiratory failure: Current use and evolving applications. ASAIO J. 2014;60:255–262
2. Rosenberg AA, Haft JW, Bartlett R, et al. Prolonged duration ECMO for ARDS: Futility, native lung recovery, or transplantation? ASAIO J. 2013;59:642–650
3. Paden ML, Conrad SA, Rycus PT, Thiagarajan RR, Registry E. Extracorporeal life support organization registry report 2012. ASAIO J. 2013;59:202–210
4. Mohite PN, Sabashnikov A, Reed A, et al. Extracorporeal life support in “awake” patients as a bridge to lung transplant. Thorac Cardiovasc Surg. 2015
5. Mullany DV, Bull TN, Hunt W, et al. Outcomes of the first 30 cases of an adult extracorporeal membrane oxygenation program: Strategies to manage the “learning curve” and implications for intensive care unit risk adjustment models. Crit Care Resusc. 2012;14:119–129
6. Wiktor AJ, Haft JW, Bartlett RH, Park PK, Raghavendran K, Napolitano LM. Prolonged VV ECMO (265 Days) for ARDS without technical complications. ASAIO J. 2015;61:205–206
7. Strecker T, Münch F, Weyand M. One hundred ten days of extracorporeal membrane oxygenation in a young woman with postpartum cerebral venous thrombosis and acute respiratory distress syndrome. Heart Surg Forum. 2012;15:180–E181
8. Ramanathan K, Cove ME, Caleb MG, Teoh KL, Maclaren G. Ethical dilemmas of adult ECMO: Emerging conceptual challenges. J Cardiothorac Vasc Anesth. 2015;29:229–233