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CHAPTER 55: Extracorporeal Respiratory Support

Madhavi Parekh; Darryl Abrams; Cara Agerstrand; Daniel Brodie

KEY POINTS

KEY POINTS

  • Extracorporeal membrane oxygenation (ECMO) is a form of extracorporeal life support (ECLS) that can provide gas exchange support in cases of severe acute respiratory failure.

  • Venovenous ECMO (VV ECMO) is the configuration most commonly used for respiratory support, especially for the management of severe acute respiratory distress syndrome (ARDS).

  • Extracorporeal carbon dioxide removal (ECCO2R) may be useful in patients with less severe ARDS or in other diseases that primarily feature hypercapnia over hypoxemia.

  • ECMO may also provide benefit for a variety of severe acute respiratory illnesses other than ARDS as well as chronic respiratory failure, especially as a bridge-to-transplantation.

  • ECMO is a complex system that has both benefits and risks, and requires expert management with regards to the circuit, patient, and potential complications.

  • ECMO has played a role in emerging diseases, notably severe ARDS secondary to coronavirus infection 2019 (COVID-19).

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is a form of extracorporeal life support (ECLS) that can provide gas exchange support in cases of severe respiratory failure. ECLS includes a broad range of extracorporeal techniques to provide cardiopulmonary support in the setting of cardiac or lung failure. ECMO is more specifically defined as a method of extracorporeal support that draws venous blood from the body through a cannula via a pump, passes through an artificial lung or oxygenator, and reinfuses well-oxygenated blood back into the body through a reinfusion cannula, and has the ability to provide circulatory or gas exchange support.1,2

Venovenous ECMO (VV ECMO) is the configuration most commonly used for respiratory support. While most often utilized and best studied in the management of severe acute respiratory distress syndrome (ARDS), ECMO may provide a benefit for a variety of severe acute, as well as chronic causes of respiratory failure. This chapter examines the historical perspective, rationale, current evidence, indications, potential complications, and role in emerging diseases such as coronavirus disease 2019 (COVID-19) of ECMO as a form of respiratory support.

TYPES OF EXTRACORPOREAL SUPPORT AND NOMENCLATURE

ECLS refers to the broad range of extracorporeal techniques that provide cardiopulmonary support, and can be broken further down into ECMO and extracorporeal carbon dioxide removal (ECCO2R) Figure 55-1.1,3

FIGURE 55-1

ECLS modes and aims. AV, arteriovenous; ECPR, extracorporeal cardiopulmonary resuscitation; EISOR, extracorporeal interval support for organ retrieval; VA, venoarterial; VV, venovenous; VVA; venovenous-arterial. (Reproduced with permission from Conrad SA, Broman LM, Taccone FS, et al. The Extracorporeal Life Support Organization Maastricht Treaty for Nomenclature in Extracorporeal Life Support. A Position Paper of the Extracorporeal Life Support Organization. Am J Respir Crit Care Med. 2018;198(4):447-451.)

A table shows ECLS modes and aims. The table is titled ‘Extracorporeal Life Support (ECLS). The column headers which show the systems are Extracorporeal Membrane Oxygenation (ECMO) and Extracorporeal Carbon Dioxide (ECCO2R). The row headers are support mode, condition, and application. The data given in the table column-wise are as follows: Extracorporeal Membrane Oxygenation (ECMO): Column 1: VA ECMO; Cardiac failure; Cardiac ECMO, ECPR, and EISOR.Column 2: VVA ECMO; Cardiorespiratory failure; Cardiac and Respiratory ECMO. Column 3: VV ECMO; Respiratory failure; Respiratory ECMO. Extracorporeal Carbon Dioxide (ECCO2R): Column 1 and column 2: VV ECCO2 R and AV ECCO2R: CO2 retention and lung protection.
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ECMO

ECMO may be subdivided, based on configuration or support mode, into venovenous (VV ECMO), venoarterial (VA ECMO), or hybrid configurations, ...

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