Extracorporeal membrane oxygenation as rescue therapy for severe ARDS due to autoimmune diffuse alveolar haemorrhage

Background: Diffuse alveolar haemorrhage (DAH) is a potentially catastrophic vasculitis manifestation which can progress to severe ARDS. Extracorporeal membrane oxygenation (ECMO) is traditionally considered contraindicated with active bleeding and little data exist on its implementation in DAH. Aims and Objectives: To analyse short-term outcome of patients with autoimmune DAH and ARDS with and without veno-venous (VV-)ECMO. Methods: We retrospectively analysed all cases with severe ARDS due to autoimmune DAH admitted to the medical ICU for survival. VV-ECMO was implemented in refractory hypoxemia despite maximized ventilator support. Results: Between 2008 and 2018, we identified 28 patients with severe ARDS due to DAH requiring mechanical ventilation. Underlying diagnosis was ANCA-associated vasculitis (82%), anti-GBM disease (7%) and other vasculitides (11%). In 19 patients (68%), VV-ECMO was implemented for refractory hypoxemia despite maximised lung-protective mechanical ventilation and immunosuppression with high-dose steroids (100%), plasma exchange (95%), cyclosphosphamide (63%) and rituximab (21%). Overall, survival was 61% (53% with VV-ECMO vs 78% on mechanical ventilation without ECMO); HR for mortality on univariate cox regression was 1.9 (95%CI 0.4-9.0), p=0.410. In the ECMO group, mortality was due to cerebral haemorrhage (33%), secondary septic multi-organ failure (44%) and refractory respiratory failure (22%). Conclusions: In refractory hypoxemic ARDS due to autoimmune DAH intra-hospital survival with VV-ECMO therapy was 53%. The data suggest that ECMO is a feasible rescue strategy for these per se non-eligible patients with active alveolar bleeding.