Use of extracorporeal membrane oxygenation in combination with high‐frequency oscillatory ventilation in post‐traumatic ARDS

Abstract

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life-threatening complications in trauma patients. Despite the implantation of a veno-venous extracorporeal membrane oxygenation (vv ECMO), sufficient oxygenation (arterial SaO(2) > 90%) is not always achieved. The additive use of high-frequency oscillation ventilation (HFOV) and ECMO in the critical phase after trauma could prevent the occurrence of life-threatening hypoxaemia and multi-organ failure. We report on a 26-year-old female (Injury Severity Score 29) who had multiple injuries as follows: an unstable pelvic fracture, a blunt abdominal trauma, a blunt trauma of the left thigh, and a thoracic injury. Three days after admission, the patient developed fulminant ARDS (Murray lung injury score of 11 and Horovitz-Index <80 mmHg), and vv ECMO therapy was initiated. The Horovitz-Index was <80 mm Hg, and the lung compliance was minimal. With HFOV, almost complete recruitment of the lung was achieved, and the fraction of inspired oxygen (FiO(2) ) was significantly reduced. The pelvic fracture was treated non-operatively. The HFOV was terminated after 3 days, and the ECMO was stopped after 19 days.

Is the use of high frequency oscillatory ventilator beneficial in managing severe chest injury with massive air leak?

“…However, the facility is available in very few centres. Gothner et al 6 used extracorporeal membrane oxygenation in combination with high-frequency oscillatory ventilation in post-traumatic ARDS.…”

Extracorporeal membranous oxygenation (ECMO) in polytrauma: what the radiologist needs to know

“…ECMO is increasingly used in trauma patients to support gas exchange while maintaining ventilation strategies that minimize or avoid further lung injury from high ventilator pressure and biotrauma from high fraction of inspired oxygen [15,17,27]. The potential for exacerbation of acute lung injury as a result of baro-and biotrauma from ventilator trials has shifted focus on using ECMO to promote lung rest earlier in the patient's course when lung injury is potentially reversible [4,5,14,17,23,[33][34][35][36]54].…”

“…It is important to document improvement or worsening in lung recruitment on follow-up chest x-rays and CT scans as changes in atelectasis may in part reflect changes in ventilator strategies [35] as well as development or successful evacuation of secretions and clotted blood [36]. Pneumothorax is common in ARDS patients [35], but in the absence of bronchopleural fistula, usually improves once ECMO is instituted.…”

“…Early aggressive use of ECMO in trauma can reverse the vicious cycle of metabolic acidosis, hypothermia, and coagulopathy leading to multi-organ system failure [4,[29][30][31][32][33]. Patients have traditionally been started on ECMO as a salvage therapy when trials with all other therapeutic modalities have failed [5,14,21,34], however, with the decreased dependence on anticoagulation, early implementation is increasingly being called for in the trauma surgery literature for patients with traumatic injuries or trauma-related sequelae associated with low survivability, especially for injuries involving the chest [5,14,15,17,22,24,35]. With improved resuscitation techniques and increased portability of new ECMO devices, more patients can be safely transported to the CT suite.…”

Management of Blunt Pulmonary Injury

“…Although ECMO is potentially beneficial, there is risk of increased bleeding into the contused lung associated with the anticoagulant used in the ECMO circuit. [67][68][69] A detailed discussion of ECMO as a pulmonary support strategy is provided in the article by Schulman et al 70 in this issue.…”