The Use of Extracorporeal Membrane Oxygenation for COVID-19: Lessons Learned

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has seen an increase in global cases of severe acute respiratory distress syndrome (ARDS), with a concomitant increased demand for extracorporeal membrane oxygenation (ECMO). Outcomes of patients with severe ARDS due to COVID-19 infection receiving ECMO support are evolving. The need for surge capacity, practical and ethical limitations on implementing ECMO, and the prolonged duration of ECMO support in patients with COVID-19-related ARDS has revealed limitations in organization and resource utilization. Coordination of efforts at multiple levels, from research to implementation, resulted in numerous innovations in the delivery of ECMO.

Keywords: ARDS; Acute respiratory distress syndrome; COVID-19; ECMO; Respiratory failure.

Fig. 1

Algorithm flowsheet for the management of ARDS including indications for ECMO. PEEP, positive end-expiratory pressure. Pao₂:Fio₂, ratio of partial pressure of oxygen in arterial blood to the fractional concentration of oxygen in inspired air. ECMO = extracorporeal membrane oxygenation. Paco₂, partial pressure of carbon dioxide in arterial blood. ^aWith respiratory rate increased to 35 breaths per minute and mechanical ventilation settings adjusted to keep a plateau airway pressure of 32 cm or less of water. ^bConsider neuromuscular blockade. ^cThere are no absolute contraindications that are agreed on except end-stage respiratory failure when lung transplantation will not be considered; exclusion criteria used in the extracorporeal membrane oxygenation for severe acute respiratory distress syndrome (EOLIA)EOLIA trial can be taken as a conservative approach to contraindications to ECMO. ^dFor example, neuromuscular blockade, high PEEP strategy, inhaled pulmonary vasodilators, recruitment maneuvers, high-frequency oscillatory ventilation. ^eRecommend early ECMO as per EOLIA trial criteria; salvage ECMO, which involves deferral of ECMO initiation until further decompensation (as in the crossovers to ECMO in the EOLIA control group), is not supported by the evidence but might be preferable to not initiating ECMO at all in such patients.

Fig. 2

Specific considerations for ECMO for COVID-19-related ARDS that may differ from ECMO for non-COVID-19 ARDS. RV, right ventricular.

Fig. 3

Patient selection and contingency flowsheet for ECMO during a pandemic. Contraindications algorithm for V-A and V-V ECMO use (COVID-19 and non-COVID-19) during a pandemic based on system capacity. ^aThe impact of duration on high-flow nasal cannula and/or noninvasive mechanical ventilation in addition to invasive mechanical ventilation is unknown. COVID-19, coronavirus disease 2019; CPR, cardiopulmonary resuscitation; ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit; Paco₂, partial pressure of carbon dioxide in arterial blood; Pao₂:Fio₂, ratio of partial pressure of oxygen in arterial blood to the fractional concentration of oxygen in inspired air; PEEP, positive end-expiratory pressure; V-A, venoarterial; V-V, venovenous.