Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used for refractory acute respiratory distress syndrome (ARDS).1–6 We report a case where VV-ECMO was used for 193 days.
A 30 year-old previously healthy Hispanic man presented to an outside hospital with 1 week history of fevers, chills, general malaise, fatigue, and productive cough. He called emergency medical services from his home because of progressive dyspnea, was intubated in the field for respiratory failure, and was initiated on vasopressors for profound circulatory compromise. Per family, patient had no previous medical history. He has been in the United States for about 10 years before the current presentation and is from Mexico. He has no known childhood illnesses. He is a nonsmoker, and has no history of alcohol or recreational drug use. He worked in construction and was exposed to occupational dust. There was no history of medication allergies. He was not on any medications as outpatient. Upon examination, patient was an obese Hispanic gentleman who was intubated and sedated. Upon arrival to the outside hospital, he was started on broad-spectrum antibiotics and antiviral agents. His ventilator was adjusted according the ARDSnet protocol, and he had refractory hypoxemia, despite maximal ventilator settings with a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of 45, consistent with severe ARDS. Our ambulatory ECMO service was called for progressive refractory hypoxemic respiratory failure, and the patient underwent cannulation via an Avalon cannula (Avalon Laboratories, Rancho Dominguez, CA) in the right internal jugular at the outside hospital. The patient was subsequently airlifted to our facility.
Vasopressors were weaned off before the patient’s arrival to our hospital. He was placed on assist control–pressure control ventilator settings and had a static compliance of 5 ml/cm H2O. The goal of the mechanical ventilation settings was to keep his plateau pressures less than 25 cm H2O. Using these goal parameters, he received 40–45 ml per breath on the ventilator. He had diffuse coarse rhonchi and tachycardia but no significant abdominal findings. His extremities were warm and perfused. His white blood cell count was 13.9 × 109/L; hemoglobin, 11.7 g/dl; creatinine, 3.6 mg/dl; phosphate, 6.3 mg/dl; total creatine kinase, 10,676; creatine kinase-MB isoenzyme, 11.5 ng/ml; and troponin-I, 0.4 ng/ml. The result of an influenza A polymerase chain reaction test was positive. The initial chest x-ray revealed diffuse opacification in his lung fields. His initial echocardiogram revealed a slightly depressed left ventricular ejection fraction at 40–45%. His right ventricle had normal systolic function. After an interdisciplinary ECMO meeting, a comprehensive plan was developed, and all services were engaged to provide low lung volume ventilation, light sedation, and initiation of continuous venovenous hemodialysis for volume removal. The patient was weaned from steroids prescribed at the previous hospital. Broad-spectrum antibiotics were prescribed and were discontinued when the cultures were negative. Notably, he received 7 days of full-strength Tamiflu for presumed viral influenza-related ARDS. He was started on heparin for anticoagulation protocol.
The patient was maintained on low tidal volume settings on the mechanical ventilator, and 5 days after cannulation, he had tension pneumothorax and underwent needle decompression. The patient had recurrent pneumothorax two additional times in the same area, which we managed conservatively with chest tube placement and removal. His chest x-ray did not show any significant recovery and the compliance remained poor over the subsequent several weeks. During this time, he was awake, alert, intubated, and on light sedation for comfort. Seven weeks after ECMO cannulation, patient was noted to have an acute mental status change and underwent a head computed tomography (CT) scan that revealed diffuse subarachnoid hemorrhage. In an interdisciplinary conference, we discussed the risks and benefits of continuing anticoagulation therapy and decided to do so with careful monitoring of his mental status. His mental status slowly improved, and he remained neurologically intact for the remainder of his hospitalization. Eight weeks after the ECMO cannulation, patient was noted to be hypoxemic, and a full evaluation for hypoxemia while on VV-ECMO included assessment of right ventricular dysfunction. He was noted to have severe right ventricular dysfunction secondary to severe lung disease. A CT pulmonary embolism protocol ruled out pulmonary embolus as a potential contributing etiology. We started inotropic support for the right ventricle, and the patient’s oxygenation improved slowly, and he was weaned off milrinone support over the following week. His course was subsequently complicated by repeated episodes of bronchopneumonia, and he was appropriately treated with antibiotics with improvement in respiratory secretions. He underwent physical therapy daily and continued physical therapy with the VV-ECMO cannula in place.
After a prolonged hospitalization of 193 days, the patient was successfully decannulated from VV-ECMO and discharged 85 days after decannulation. At the time of discharge, he was dependent on supplemental oxygen via tracheostomy. He was able to take care of himself and walk 500 feet independently without support. The patient is receiving follow-up at our outpatient interdisciplinary pulmonary–heart failure clinic and is trying to establish Texas residency to qualify for lung transplantation.
The use of ECMO to replace lung function in ARDS was initially proposed more than 40 years ago and successfully implemented in 1971. In the following decades, complications and mortality were high, and randomized control trials showed no benefit of now-outdated ECMO technology more than mechanical ventilation.1 The Extracorporeal Life Support Organization (ELSO) was formed in 1989 and includes about 100 cases per year until the mid 2000s when ECMO usage increased. Advances in device technology and the 2009 H1N1 influenza pandemic improved our understanding of ECMO in severe refractory ARDS. The ELSO recorded a surge in reported ECMO cases in 2009, when more than 400 cases were reported to the registry.2 During the 2009 pandemic, various centers worldwide reported survival rates from 52% to 79% on ECMO.3–6
Also in 2009, the efficacy and economic assessment of conventional ventilator support versus ECMO for severe adult respiratory failure (CESAR)7 trial showed a 16% absolute reduction in disability at 6 months in the ECMO-referred group. This randomized control trial also showed an increased proportion of lung-protective ventilation. Mortality was lower in the ECMO-referred group, although the study lacked power to show a statistically significant difference. The study lacked a standardized treatment protocol in the conventional management group, so the superiority of ECMO remains controversial. Although use of ECMO remains high after the 2009 pandemic subsided, further trials are needed to determine whether ECMO improves mortality in the setting of ARDS.
The median duration of ECMO therapy in adult severe ARDS patients is commonly reported as 7–10 days.1,8,9 In the ELSO Registry Report 2012,2 the mean time on extracorporeal life support is 177 hours (7.4 days). At that time, the longest adult case in their registry was 5,014 hours (208.9 days), although patients on longer duration support have been reported.9
There are currently no studies that suggest the optimal duration of VV-ECMO support, and there are no criteria for when to consider futility or lung transplantation. Instead, recovery depends on individual patient’s response to his/her illness. There are reports of prolonged ECMO that demonstrate partial native lung recovery on prolonged mechanical ventilation by serial pulmonary function tests8 or by complete recovery without respiratory support.10 In the present case, lung recovery was sufficient to allow hospital discharge and ambulation on supplemental oxygen via tracheostomy while awaiting lung transplantation.
Technical improvements and miniaturization of ECMO have resulted in fewer complications and allow for extracorporeal support in awake and ambulatory patients. Patients who are awake on ECMO are able to relay subjective information such as pain or abdominal distension, which aids in earlier diagnosis or prevention of complications such as respiratory or gastrointestinal tract infections.11 In the present case, the patient was mildly sedated but awake enough to allow detection of acute mental status change and diagnosis of diffuse subarachnoid hemorrhage.
Smaller ECMO systems and single-cannula access allow early mobility and ambulation that allow breathing exercises and physical therapy to avoid pressure sores, bone loss, and muscle loss.11 An Ann Arbor, Michigan group reported a woman on ECMO support for 265 days without complications who died because of pulseless electrical activity arrest 4 days after decannulation.8 She was supported on a bicaval dual-lumen Avalon cannula and participated in moderate exercise with bicycle reconditioning. Our patient was able to participate in physical therapy on VV-ECMO and could ambulate at the time of discharge despite a prolonged hospital stay.
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