Bronchial fistulae in ARDS patients: management with an extracorporeal lung assist device

Abstract

Patients with bronchial tree lesions feature, in particular, a high risk for developing bronchial fistulae after surgical repair when the clinical situation is complicated by acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) and mechanical ventilation is needed. The current authors hypothesised that extracorporeal carbon dioxide removal would significantly decrease inspiratory airway pressures, thus promoting the protection of surgical bronchial reconstruction.Four patients were studied after surgical reconstruction of bronchial fistulae in whom ALI/ARDS developed and mechanical ventilation with positive end-expiratory pressure was required. Gas exchange, tidal volumes, airway pressures, respiratory frequency, vasopressor and sedation requirements were analysed before and after initiation of a pumpless extracorporeal lung assist device (pECLA; NovaLung1, Talheim, Germany). Initiation of pECLA treatment enabled a reduction of inspiratory plateau airway pressures from 32.4 to 28.6 cmH 2 O (3.2 to 2.8 kPa), effectively treated hypercapnia (from 73.6 to 53.4 mmHg (9.8 to 7

Extracorporeal lung assist: more than kicking a dead horse?

“…In all four patients, the use of pECLA corrected hypercapnia and enabled the reduction of airway pressures, and all patients were eventually discharged from the hospital. As HOMMEL et al [12] point out in their paper, there is no proof that the use of pECLA was responsible for the good outcome but there are compelling pathophysiological reasons supporting this hypothesis.…”

“…In the present issue of the European Respiratory Journal, HOMMEL et al [12] report on four patients with ARDS and bronchopleural fistulas with persistent air leakage despite surgical interventions. These patients usually have a poor prognosis if they develop respiratory failure and require mechanical ventilation with high airway pressures.…”

Extracorporeal Carbon Dioxide Removal (ECCO2R) in Respiratory Failure: An Overview, and where Next?

“…Overall, there is good evidence that ECCO 2 R can effectively reduce PaCO 2 and make a small contribution to oxygenation in patients with ARDS. Likewise, studies 14,[18][19][20]22,23 have demonstrated that ECCO 2 R facilitates a lung-protective ventilation strategy by allowing a reduction in tidal volumes and inspiratory airway pressures. ECCO 2 R may even complement specific forms of protective ventilation such as HFOV 21,24 or APRV (Airway Pressure Release Ventilation) with 2-4 mL/kg tidal volumes.…”

“…There are a number of reports of its use in other clinical scenarios, namely, as a bridge to transplant, 11,25 in combined head and chest injury, 7,8,26 in near fatal asthma, [27][28][29] as an aid to weaning from mechanical ventilation, 12,30 to facilitate thoracic surgery 19,22,31 and to facilitate transfer. 32,33 However, these are all case reports or very small case series and as such do not provide any definitive evidence of benefit.…”

“…Within these 18 citations, there were no randomised controlled trials, a single health technology assessment 15 and only two prospective interventional studies 10,14 both of which have already been summarised. The remainder of the relevant literature was confined to either prospective or retrospective case series [16][17][18][19][20][21][22][23][24] although these do demonstrate that ECCO 2 R has been used on over 500 patients (with no unifying database). Overall, there is good evidence that ECCO 2 R can effectively reduce PaCO 2 and make a small contribution to oxygenation in patients with ARDS.…”