Extracorporeal Membrane Oxygenation in Acute Respiratory Failure

Abstract

Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a form of mechanical life support that provides full respiratory bypass in patients with severe respiratory failure as a bridge to recovery or lung transplantation. The use of ECMO for respiratory failure and capable centers offering ECMO has expanded over the years, increasing its availability. As VV-ECMO provides an artificial mechanism for oxygenation and decarboxylation of native blood, it allows for an environment in which safer mechanical ventilatory care may be provided, allowing for treatment and resolution of underlying respiratory pathologies. Landmark clinical trials have provided a framework for better understanding patient selection criteria, resource utilization, and outcomes associated with ECMO when applied in settings of refractory respiratory failure. Maintaining close vigilance and management of complications during ECMO as well as identifying strategies post-ECMO (e.g., recovery, transplantation, etc.), are critical to successful ECMO support. In this review, we examine considerations for candidate selection for VV-ECMO, review the evidence of utilizing VV-ECMO in respiratory failure, and provide practical considerations for managing respiratory ECMO patients, including complication identification and management, as well as assessing for the ability to separate from ECMO support and the procedures for decannulation.

Keywords: ARDS; ECLS; ECMO; Extracorporeal support; Respiratory failure.

Fig. 1

International trends of cumulative number of ECMO centers worldwide (bars) and annual number of adult respiratory ECMO runs (line) over time (data sourced from the Extracorporeal Life Source Organization Registry [3])

Fig. 2

Example VV-ECMO circuit configurations utilizing a two-cannula approach. a Right femoral vein to right internal jugular vein. b Left femoral vein to right femoral vein. Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved

Fig. 3

Example VV-ECMO circuit configurations utilizing a single dual-lumen cannula approach. a Dual-lumen cannula via right internal jugular vein access. b Dual-lumen cannula pseudo-right ventricular assist device configuration via left subclavian vein access. Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved

Fig. 4

Multistage femoral venous drainage cannula (a), jugular vein return cannula (b), and corresponding chest film of VV-ECMO configuration with a right femoral multistage venous drainage cannula and a right internal jugular vein return cannula (c). Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved

Fig. 5

Dual-lumen cannula (a) with corresponding chest film with cannula placed via left subclavian access (b). Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved

Fig. 6

A roadmap for weaning from VV-ECMO. ABG arterial blood gas, RR respiratory rate