Ambulatory veno-venous extracorporeal membrane oxygenation: Innovation and pitfalls

Abstract

Improvements in the durability of membrane blood oxygenators and pumps have prompted renewed consideration of extracorporeal membrane oxygenation in patients with severe lung disease. This report describes an attempt to augment extracorporeal membrane oxygenation with the goal of ambulation by minimizing mechanical ventilatory support and using aggressive in-and-out-of-bed rehabilitation.

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

“…Currently, only a limited number of programs follow the practice of active rehabilitation and ambulation while on ECMO [12][13][14]28 ; however, this practice is growing. The employment of ambulatory ECMO as a bridge to lung transplantation is a complex process that has high-resource utilization.…”

Overview of Clinical Lung Transplantation

“…Novel bicaval dual lumen cannulas, such as the Avalon cannula, allow venous -venous ECMO to be started via a single cannulation site in the neck (Wang et al 2008). In case series, patients awaiting lung transplantation have avoided intubation and could continue an exercise regimen while on ECMO (Garcia et al 2011;.…”

A Step Up for Extracorporeal Membrane Oxygenation: Active Rehabilitation

“…Other studies have reported successful rehabilitation with treadmill walking, 16 and transfers from bed to chair. 4 Early mobilization may be an important intervention to reduce the negative side effects of intubation, mechanical ventilation, and bed rest. 20 It may be particularly important in the cohort of patients who are critically ill pretransplant and require ECMO as a bridge to transplant with an uncertain waiting period for donor lungs.…”

“…There may also be potential for the use of extracorporeal life support in other patient populations to facilitate rehabilitation and prevent intubation, such as severe respiratory failure with ARDS or exacerbations of COPD. 4 Indeed, recent case series have demonstrated the feasibility of using low-flow extracorporeal carbon dioxide removal to obviate the need for invasive mechanical ventilation in hypercapnic COPD patients failing noninvasive ventilation. 21,22 However, many of the patients in these studies had femoral cannulation, limiting the ability to provide more intensive rehabilitation, which may have synergistic benefits when coupled with reduced analgosedation off invasive mechanical ventilation.…”

“…[1][2][3][4] It is recognized that as the lungs fail, invasive mechanical ventilation may not fulfill the optimal goals as a bridge to transplant. There have now been several international reports of ECMO as a successful bridge to transplant in patients who are awake and non-ventilated ("awake ECMO").…”