An International Survey on Ventilator Practices Among Extracorporeal Membrane Oxygenation Centers

Abstract

Although the optimal ventilation strategy is unknown for patients placed on extracorporeal support, there are increasing reports of extubation being used. Our objective was to describe the change in ventilation strategies and use of tracheostomy and bronchoscopy practices among extracorporeal membrane oxygenation (ECMO) centers across the world. A descriptive, cross-sectional 22 item survey of neonatal, pediatric, and adult ECMO centers was used to evaluate ventilator strategies, extubation, bronchoscopy, and tracheostomy practices. Extubation practices are increasing among all types of ECMO centers, representing 27% of all patients in pediatric centers, 41% of all patients in mixed centers, and 52% of all patients in adult centers. The most common mode of ventilation during ECMO is pressure control. There is a trend toward increased use of bilevel ventilation particularly for lung recruitment. Additionally, there is a trend toward increase in performance of bronchoscopy (pediatrics: 69%, mixed centers: 81%, adults: 76%) and tracheostomy. Among the centers performing tracheostomies, 45% reported the percutaneous method (pediatric: 31%, mixed: 46%, adult: 57%), 19% reported the open method (pediatric: 9%, mixed: 27%, adult: 24%), and 10% reported using both types of tracheostomies (pediatric: 2%, mixed: 8%, adult: 16%). Our study shows that ECMO centers are extubating their patients, performing tracheostomies and bronchoscopies on their patients more than in the previous years. There remains significant variation in ECMO ventilator strategies and management internationally. Future studies are needed to correlate these changes in practices to outcome benefits.

Extracorporeal Membrane Oxygenation for Acute Pediatric Respiratory Failure

“…The need for re-recruitment may prolong the ECMO course and contribute to VILI. Given this concern, some intensivists no longer practice strict "lung rest" while on ECMO for ARDS [90]. The most popular new ventilation practice is an open-lung strategy on ECMO, similar to the adult ARDS low V T ventilation strategy [91].…”

“…Though there are only a few reports of bronchoscopy on ECMO in the literature [98][99][100][101], it is commonly implemented in clinical practice. Routine bronchoscopy of patients on ECMO is performed in 55% of pediatric ECMO centers and 76% of adult centers [90]. While the benefits of bronchoscopy on ECMO have not been established in the literature, they are often seen at the bedside in patients with thick respiratory secretions that cannot be mobilized through traditional suctioning techniques.…”

“…The practice of extubation on ECMO has becoming increasingly utilized in the past several years. In a 2015 survey, only 10% of centers reported extubating patients on ECMO, while a 2017 survey reported 41% of centers extubate patients [90,91]. ECMO is employed to allow for oxygenation and ventilation without the risk of VILI.…”

A winter to remember! Extracorporeal membrane oxygenation for life‐threatening asthma in children: A case series and review of literature

“…In addition, a study looking at pediatric respiratory failure and ECMO support found a diagnosis of asthma to be independently associated with lower mortality with the lowest mortality of any diagnostic group . Extubation while on ECMO support is being increasingly utilized with more than 50% adult centers and more than 25% pediatric centers reporting it . We describe our recent experience of three patients in the winter of 2018‐2019 with NFA requiring ECMO support and review the current literature on this subject.…”

“…3 Extubation while on ECMO support is being increasingly utilized with more than 50% adult centers and more than 25% pediatric centers reporting it. 5 We describe our recent experience of three patients in the winter of 2018-2019 with NFA requiring ECMO support and review the current literature on this subject. The requirement for patient consent to publish this case report was waived by our Institutional Review Board in accordance with their policy.…”