Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome associated with COVID-19: a retrospective cohort study

Abstract

Summary Background Patients with COVID-19 who develop severe acute respiratory distress syndrome (ARDS) can have symptoms that rapidly evolve to profound hypoxaemia and death. The efficacy of extracorporeal membrane oxygenation (ECMO) for patients with severe ARDS in the context of COVID-19 is unclear. We aimed to establish the clinical characteristics and outcomes of patients with respiratory failure and COVID-19 treated with ECMO. Methods This retrospective cohort study was done in the Paris–Sorbonne University Hospital Network, comprising five intensive care units (ICUs) and included patients who received ECMO for COVID-19 associated ARDS. Patient demographics and daily pre-ECMO and on-ECMO data and outcomes were collected. Possible outcomes over time were categorised into four different states (states 1–4): on ECMO, in the ICU and weaned off ECMO, alive and out of ICU, or death. Daily probabilities of occupation in each state and of transitions between these states until day 90 post-ECMO onset were estimated with use of a multi-state Cox model stratified for each possible transition. Follow-up was right-censored on July 10, 2020. Findings From March 8 to May 2, 2020, 492 patients with COVID-19 were treated in our ICUs. Complete day-60 follow-up was available for 83 patients (median age 49 [IQR 41–56] years and 61 [73%] men) who received ECMO. Pre-ECMO, 78 (94%) patients had been prone-positioned; their median driving pressure was 18 (IQR 16–21) cm H 2 O and PaO 2 /FiO 2 was 60 (54–68) mm Hg. At 60 days post-ECMO initiation, the estimated probabilities of occupation in each state were 6% (95% CI 3–14) for state 1, 18% (11–28) for state 2, 45% (35–56) for state 3, and 31% (22–42) for state 4. 35 (42%) patients had major bleeding and four (5%) had a haemorrhagic stroke. 30 patients died. Interpretation The estimated 60-day survival of ECMO-rescued patients with COVID-19 was similar to that of studies published in the past 2 years on ECMO for severe ARDS. If another COVID-19 outbreak occurs, ECMO should be considered for patients developing refractory respiratory failure despite optimised care. Funding None.

ECMO for severe ARDS: systematic review and individual patient data meta-analysis

“…Ultraprotective ventilation with very low VTs, driving pressures and respiratory rates [35], and, therefore, minimized overall mechanical power transmitted to lung alveoli [36] may reduce ventilator-induced lung injury, pulmonary and systemic inflammation and ultimately organ failure leading to death. These data also reinforce the recent recommendation of the World Health Organization (WHO) [37], and the Surviving Sepsis Campaign [38] to consider ECMO support in coronavirus disease 2019 (COVID-19)-related ARDS with refractory hypoxemia if lung protective mechanical ventilation was insufficient to support the patient [39].…”

What have we learned ventilating COVID-19 patients?

“…However, recent studies suggest that COVID-19 patients placed on ECMO have reasonable outcomes. In a series of 83 patients with severe COVID-19 ARDS treated with ECMO, estimated 60-day mortality (31%) was similar to previous studies of severe classical ARDS [14]. A recent study using the Extracorporeal Life Support Organization (ELSO) Registry examined the outcomes of 1035 COVID-19 patients who received ECMO [15].…”

What’s new in ECMO for COVID-19?

“…4 Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, USA. 5 Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, USA.…”

“…A multicentre French study captured the early experience with critically ill COVID-19 patients after the first wave of the pandemic hit Western Europe [5]. Eightythree (17%) of 492 intensive care patients with COVID-19-related acute respiratory distress syndrome (ARDS) received ECMO and were ultimately assessed to have an estimated probability of 60-day mortality of 31% (95% CI 22-42).…”

“…Some reports highlighted the use of relatively novel management strategies consisting of bundled treatment elements, each of which had been applied in patients prior to the pandemic, but were now being trialed more systematically in patients with COVID-19. For example, in the multicentre French study cited earlier [5], 81% of the patients were nursed in the prone position during ECMO. It is unknown whether this practice leads to better outcomes but there is preliminary evidence suggesting that it may be associated with lower mortality [10,11].…”