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Review
. 2022 Oct;48(10):1326-1337.
doi: 10.1007/s00134-022-06815-w. Epub 2022 Aug 9.

Respiratory indications for ECMO: focus on COVID-19

Alexander Supady  1   2 , Alain Combes #  3   4 , Ryan P Barbaro  5 , Luigi Camporota  6   7 , Rodrigo Diaz  8 , Eddy Fan  9   10   11 , Marco Giani  12 , Carol Hodgson  13   14   15   16 , Catherine L Hough  17 , Christian Karagiannidis  18 , Matthias Kochanek  19 , Ahmed A Rabie  20 , Jordi Riera  21 , Arthur S Slutsky #  9   22 , Daniel Brodie #  23   24
Affiliations
Review

Respiratory indications for ECMO: focus on COVID-19

Alexander Supady et al. Intensive Care Med. 2022 Oct.

Abstract

Extracorporeal membrane oxygenation (ECMO) is increasingly being used for patients with severe respiratory failure and has received particular attention during the coronavirus disease 2019 (COVID-19) pandemic. Evidence from two key randomized controlled trials, a subsequent post hoc Bayesian analysis, and meta-analyses support the interpretation of a benefit of ECMO in combination with ultra-lung-protective ventilation for select patients with very severe forms of acute respiratory distress syndrome (ARDS). During the pandemic, new evidence has emerged helping to better define the role of ECMO for patients with COVID-19. Results from large cohorts suggest outcomes during the first wave of the pandemic were similar to those in non-COVID-19 cohorts. As the pandemic continued, mortality of patients supported with ECMO has increased. However, the precise reasons for this observation are unclear. Known risk factors for mortality in COVID-19 and non-COVID-19 patients are higher patient age, concomitant extra-pulmonary organ failures or malignancies, prolonged mechanical ventilation before ECMO, less experienced treatment teams and lower ECMO caseloads in the treating center. ECMO is a high resource-dependent support option; therefore, it should be used judiciously, and its availability may need to be constrained when resources are scarce. More evidence from high-quality research is required to better define the role and limitations of ECMO in patients with severe COVID-19.

Keywords: ARDS; Acute respiratory distress syndrome; COVID-19; ECMO; Extracorporeal circulation; Extracorporeal membrane oxygenation; Resource limitations; Respiratory failure.

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Conflict of interest statement

All authors have completed the ICMJE form (available upon request from the corresponding author). AS reports research grants and lecture fees from CytoSorbents and lecture fees from Abiomed, both outside the submitted work. EF received research support from Abbott and LivaNova and consulting fees from ALung Technologies, Vasomune, Baxter and GE Healthcare. CH is supported by an Australian NHMRC Investigator grant and leads the Australian and New Zealand ECMO Registry. CK received consulting fees from Xenios/ Fresenius and Bayer. He is Chair of the German ICU Registry and President of the German Society of Medical Intensive Care. JR reports lecture and advisory fees from Medtronic and Werfen, outside the submitted work. ASS has been on medical advisory boards for Baxter and Xenios; he is Chair of the Scientific Committee of the Committee of the International ECMO Network (ECMONet). DB receives research support from ALung Technologies. He has been on the medical advisory boards for Abiomed, Xenios, Medtronic, Inspira and Cellenkos. He is the President-elect of the Extracorporeal Life Support Organization (ELSO) and the Chair of ECMONet. All other authors report no conflicts of interest.

Figures

Fig. 1
Fig. 1
Mortality rates from selected ECMO cohorts during the first and later waves of the pandemic. In all reported cohorts, mortality rates were reported for variably defined later waves, compared to the first wave. Differences in outcomes between the cohorts may be, at least in part, explained by differences in inclusion and exclusion criteria (see main text for details). Broman et al. and Barbaro et al. reported data from large international cohorts confirming the observation of increasing mortality with the use of ECMO after the first wave of the pandemic. ECMO extracorporeal membrane oxygenation, ARDS acute respiratory distress syndrome, COVID-19 coronavirus disease 2019
Fig. 2
Fig. 2
Key strategies of care that may be initiated, including consideration of ECMO support in patients with ARDS (non-COVID-19 and COVID-19-related). ECMO extracorporeal membrane oxygenation, ARDS acute respiratory distress syndrome, COVID-19 coronavirus disease 2019, PEEP positive end-expiratory pressure
Fig. 3
Fig. 3
Patient-related and center-associated factors contributing to the risk of mortality in patients supported with venovenous ECMO, with a focus on COVID-19-related ARDS. ECMO extracorporeal membrane oxygenation, ARDS acute respiratory distress syndrome, COVID-19 coronavirus disease 2019
See this image and copyright information in PMC

References

    1. Brodie D, Slutsky AS, Combes A. Extracorporeal life support for adults with respiratory failure and related indications: a review. JAMA. 2019;322:557–568. doi: 10.1001/jama.2019.9302. - DOI - PubMed
    1. MacLaren G, Fisher D, Brodie D. Preparing for the most critically Ill patients with COVID-19: the potential role of extracorporeal membrane oxygenation. JAMA. 2020;323:1245–1246. doi: 10.1001/jama.2020.2342. - DOI - PubMed
    1. MacLaren G, Fisher D, Brodie D. Treating the most critically Ill patients with COVID-19: the evolving role of extracorporeal membrane oxygenation. JAMA. 2022;327:31–32. doi: 10.1001/jama.2021.22580. - DOI - PubMed
    1. Brodie D, Abrams D, MacLaren G, Brown CE, Evans L, Barbaro RP, Calfee CS, Hough CL, Fowles JA, Karagiannidis C, Slutsky AS, Combes A. ECMO During Respiratory Pandemics: Past, Present, and Future. Am J Respir Crit Care Med. 2022 doi: 10.1164/rccm.202111-2661CP. - DOI - PMC - PubMed
    1. Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, Hibbert CL, Truesdale A, Clemens F, Cooper N, Firmin RK, Elbourne D, collaboration Ct, Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374:1351–1363. doi: 10.1016/S0140-6736(09)61069-2. - DOI - PubMed