Severe Hypoxemic Respiratory Failure

Raoof, Suhail; Goulet, Keith; Esan, Adebayo; Hess, Dean; Sessler, Curtis N.

doi:10.1378/chest.09-2416

Cited by 135 publications

(24 citation statements)

References 95 publications

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“…[1,2] According to the database of Extracorporeal Life Support Organization (ELSO) registered from 2000 to 2012, the overall salvage rate of ECMO for ARF in adults is 57%. [3] The venovenous (VV) mode is the preferred mode of ECMO in this setting, and yields a significantly higher survival rate when compared with venoarterial (VA) ECMO (VV vs VA: prevalence 82% vs 23%; survival rate 60% vs 40%; P < 0.001).…”

Section: Introductionmentioning

confidence: 99%

Venovenous extracorporeal membrane oxygenation in adult respiratory failure

Hsin

Huang

et al. 2016

Medicine

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Despite a potentially effective therapy for adult respiratory failure, a general agreement on venovenous extracorporeal membrane oxygenation (VV-ECMO) has not been reached among institutions due to its invasiveness and high resource usage. To establish consensus on the timing of intervention, large ECMO organizations have published the respiratory extracorporeal membrane oxygenation survival prediction (RESP) score and the ECMOnet score, which allow users to predict hospital mortality for candidates with their pre-ECMO presentations. This study was aimed to test the predictive powers of these published scores in a medium-sized cohort enrolling adults treated with VV-ECMO for acute respiratory failure, and develop an institutional prediction model under the framework of the 3 scores if a superior predictive power could be achieved. This retrospective study included 107 adults who received VV-ECMO for severe acute respiratory failure (a PaO2/FiO2 ratio <70 mm Hg) in a tertiary referral center from 2007 to 2015. Essential demographic and clinical data were collected to calculate the RESP score, the ECMOnet score, and the sequential organ failure assessment (SOFA) score before VV-ECMO. The predictive power of hospital mortality of each score was presented as the area under receiver-operating characteristic curve (AUROC). The multivariate logistic regression was used to develop an institutional prediction model. The surviving to discharge rate was 55% (n = 59). All of the 3 published scores had a real but poor predictive power of hospital mortality in this study. The AUROCs of RESP score, ECMOnet score, and SOFA score were 0.662 (P = 0.004), 0.616 (P = 0.04), and 0.667 (P = 0.003), respectively. An institutional prediction model was established from these score parameters and presented as follows: hospital mortality (Y) = −3.173 + 0.208 × (pre-ECMO SOFA score) + 0.148 × (pre-ECMO mechanical ventilation day) + 1.021 × (immunocompromised status). Compared with the 3 scores, the institutional model had a significantly higher AUROC (0.779; P < 0.001). The 3 published scores provide valuable information about the poor prognostic factors for adult respiratory ECMO. Among the score parameters, duration of mechanical ventilation, immunocompromised status, and severity of organ dysfunction may be the most important prognostic factors of VV-ECMO used for adult respiratory failure.

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Section: Introductionmentioning

confidence: 99%

Venovenous extracorporeal membrane oxygenation in adult respiratory failure

Hsin

Huang

et al. 2016

Medicine

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“…In clinical practice, as an effort to improve oxygenation in these patients, several different “rescue therapies” are often advocated, including inhaled nitric oxide, inhaled epoprostenol and prone position ventilation (3, 11-13). However, randomized controlled trials conducted to date utilized rescue therapies as an adjunctive modality to treat ARDS, rather than a “last resort” intervention for treatment of critical hypoxemia in rapidly deteriorating patients.…”

Section: Introductionmentioning

confidence: 99%

Long-Term Survival in Patients With Severe Acute Respiratory Distress Syndrome and Rescue Therapies for Refractory Hypoxemia*

Hough

Bansal

Veenstra

2014

Critical Care Medicine

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Objective To describe long-term survival in patients with severe acute respiratory distress syndrome (ARDS) and assess differences in patient characteristics and outcomes among those who receive rescue therapies (prone position ventilation, inhaled nitric oxide, or inhaled epoprostenol) versus conventional treatment. Design and Setting Cohort study of patients with severe hypoxemia at a University-affiliated Level 1 trauma center. Patients Patients diagnosed with severe ARDS within 72 hours of ICU admission between 1/1/2008 and 12/31/2011. Methods Data were abstracted from the medical record and included demographic and clinical variables, hospital and ICU length of stay, discharge disposition, and hospital costs. Patient-level data were linked to the Washington State Death Registry. Kaplan-Meier methods and Cox's proportional hazards models were used to estimate survival and hazard ratios. Main Results 428 patients meeting study inclusion criteria were identified; 62 (14%) were initiated on a rescue therapy. PaO2/FIO2 ratios were comparable at admission between patients treated with a rescue therapy and those treated conventionally, but were substantially lower by 72 hours in those who received rescue therapies (54 ± 17 versus 69 ± 17 mmHg; p<.01). For the entire cohort, estimated survival probability at three years was 55% (95% CI: 51%, 61%). Among 280 hospital survivors (65%), three-year survival was 85% (95% CI: 80%, 89%). The relative hazard of in-hospital mortality was 68% higher among patients who received rescue therapy compared to patients treated conventionally (95% CI: 8%, 162%; p=0.02). For long-term survival, the hazard ratio of death following ICU admission was 1.56 (95% CI: 1.02, 2.37; p=0.04), comparing rescue versus conventional treatment. Conclusions Despite high hospital mortality, severe ARDS patients surviving to hospital discharge have relatively good long-term survival. Worsening hypoxemia was associated with initiation of rescue therapy. Patients on rescue therapy had higher in-hospital mortality; however, survivors to hospital discharge had long-term survival that was comparable to other ARDS survivors.

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“…By shifting blood from the lower limbs and splanchnic compartment, PLR is a safe, reversible manoeuvre that mimics fluid expansion [16]. In adult patients with refractory ARDS, despite ventilatory optimisation by means of routine therapies (protective mechanical ventilation, prone position and nitric oxide) [18,19], the use of respiratory assistance such as venovenous extracorporeal membrane oxygenation (ECMO) ensures oxygenation and decarboxylation [20-22]. Venovenous ECMO consists of a circuit supplied by a centrifugal pump without a venous reservoir.…”

Section: Introductionmentioning

confidence: 99%

Passive leg raising can predict fluid responsiveness in patients placed on venovenous extracorporeal membrane oxygenation

et al. 2011

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IntroductionIn ICUs, fluid administration is frequently used to treat hypovolaemia. Because volume expansion (VE) can worsen acute respiratory distress syndrome (ARDS) and volume overload must be avoided, predictive indicators of fluid responsiveness are needed. The purpose of this study was to determine whether passive leg raising (PLR) can be used to predict fluid responsiveness in patients with ARDS treated with venovenous extracorporeal membrane oxygenation (ECMO).MethodsWe carried out a prospective study in a university hospital surgical ICU. All patients with ARDS treated with venovenous ECMO and exhibiting clinical and laboratory signs of hypovolaemia were enrolled. We measured PLR-induced changes in stroke volume (ΔPLRSV) and cardiac output (ΔPLRCO) using transthoracic echocardiography. We also assessed PLR-induced changes in ECMO pump flow (ΔPLRPO) and PLR-induced changes in ECMO pulse pressure (ΔPLRPP) as predictors of fluid responsiveness. Responders were defined by an increase in stroke volume (SV) > 15% after VE.ResultsTwenty-five measurements were obtained from seventeen patients. In 52% of the measurements (n = 13), SV increased by > 15% after VE (responders). The patients' clinical characteristics appeared to be similar between responders and nonresponders. In the responder group, PLR significantly increased SV, cardiac output and pump flow (P < 0.001). ΔPLRSV values were correlated with VE-induced SV variations (r2 = 0.72, P = 0.0001). A 10% increased ΔPLRSV predicted fluid responsiveness with an area under the receiver operating characteristic curve (AUC) of 0.88 ± 0.07 (95% confidence interval (CI95): 0.69 to 0.97; P < 0.0001), 62% sensitivity and 92% specificity. On the basis of AUCs of 0.62 ± 0.11 (CI95: 0.4 to 0.8; P = 0.31) and 0.53 ± 0.12 (CI95: 0.32 to 0.73, P = 0.79), respectively, ΔPLRPP and ΔPLRPO did not predict fluid responsiveness.ConclusionsIn patients treated with venovenous ECMO, a > 10% ΔPLRSV may predict fluid responsiveness. ΔPLRPP and ΔPLRPO cannot predict fluid responsiveness.

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Severe Hypoxemic Respiratory Failure

Cited by 135 publications

References 95 publications

Venovenous extracorporeal membrane oxygenation in adult respiratory failure

Venovenous extracorporeal membrane oxygenation in adult respiratory failure

Long-Term Survival in Patients With Severe Acute Respiratory Distress Syndrome and Rescue Therapies for Refractory Hypoxemia*

Passive leg raising can predict fluid responsiveness in patients placed on venovenous extracorporeal membrane oxygenation

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