Ambulatory extracorporeal membrane oxygenation: A new approach for bridge-to-lung transplantation

Abstract

Extracorporeal membrane oxygenation (ECMO) for severe respiratory failure can be used to maintain adequate gas exchange but precludes ambulation and may lead to further deconditioning. We present a case of ambulatory ECMO for severe respiratory failure using a dual-lumen single cannula system. CLINICAL SUMMARYA 49-year-old man with chronic carbon dioxide retention and elevated serum bicarbonate levels awaiting lung transplantation for severe chronic obstructive pulmonary disease (COPD) had respiratory failure owing to an acute COPD exacerbation. He was admitted to the medical intensive care unit and began receiving mechanical ventilation. Arterial blood gas analysis on admission demonstrated a PO 2 of 62 mm Hg and a PCO 2 greater than 100 mm Hg. Despite aggressive treatment with steroids, inhaled bronchodilators, antibiotics, sildenafil, inhaled nitric oxide, and theophylline for 2 weeks, the patient remained ventilator dependent. He was therefore advanced to ambulatory ECMO to alleviate the need for mechanical ventilation and allow aggressive rehabilitation.Under general anesthesia in the cardiac operating theater, the internal jugular vein was located with ultrasound and marked. A small incision was made over the vein and dissection was carried down to the internal jugular vein. To allow a more comfortable lie of the proximal dual-lumen catheter FIGURE 1. Insertion of the dual-lumen cannula into the internal jugular vein by tunneling from the right subclavicular chest. Note the subtle curve of the tunneled cannula. Inflow to the ECMO circuit is from the tip of the cannula located in the inferior vena cava and fenestrations in the mid-cannula at the superior vena cava-right atrial junction. Outflow between these 2 points is directed at the tricuspid valve.

Economic Outcomes of Extracorporeal Membrane Oxygenation With and Without Ambulation as a Bridge to Lung Transplantation

“…10 Several centers use ambulatory ECMO to rehabilitate patients to mitigate deconditioning in an attempt to improve outcomes in these critically ill patients. [11][12][13][14][15] Early studies demonstrated feasibility and potentially improved outcomes with this ECMO rehabilitation strategy as a bridge to transplantation. 14,16,17 In a single-center study, subjects who were spontaneously breathing while supported with ECMO had better 1-y survival rates post-transplant than did their mechanically ventilated counterparts who were supported with ECMO and proceeded to lung transplantation.…”

Ambulatory ECMO as a Bridge to Lung Transplant in a Previously Well Pediatric Patient With ARDS

“…[8][9][10][11][12][13][14][15][16][17][18][19] Chronic respiratory insufficiency leads to greater tolerance for dyspnea, as evidenced by the patients supported with ambulatory ECMO who have been managed with minimal respiratory support or even extubated. 8,[15][16][17]19 The impact of weaning both sedation and ventilatory support in children without chronic respiratory disease must be addressed when ambulatory ECMO is considered for previously healthy children.…”

“…Traditional outcomes for ECMO patients bridged to lung transplant are poor, [4][5][6][7] but there are increasing reports of successful bridge to transplant using awake and ambulatory ECMO approaches in patients with chronic respiratory conditions. [8][9][10][11][12][13][14][15][16][17][18][19] We report the first successful bridge to lung transplant with ambulatory ECMO in a previously healthy pediatric patient with acute refractory respiratory failure.…”

Extracorporeal membrane oxygenation in the pre and post lung transplant period

“…Critically ill patients on prolonged mechanical ventilation and/ or ECMO support are prone to developing significant neuro-muscular weakness (76,77). Several studies have demonstrated that physical rehabilitation in patients on ECMO support is safe and can potentially improve post-transplant recovery and outcomes (25,29,39,78,79). Ambulation can be safely achieved in patients cannulated via a DLC in a VV configuration or subclavian/central VA configuration (48,(80)(81)(82).…”