A Case of Severe Acute Respiratory Distress Syndrome Treated with Extracorporeal Life Support
Young Mook KimJue Yong LeeMyung-Goo LeeChang Youl LeeGo Woon KimKyoung Min SohnHa Na YangDae Yong KimHyun Hee ChoiHyoung Soo Kim
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Abstract:
The incidence of acute respiratory distress syndrome (ARDS) has been estimated worldwide to range from 1.7 to 75 cases per 100,000. There are many treatments for ARDS, but only the low tidal volume strategy is based on strong clinical evidence from randomized clinical trials. The efficacy of extracorporeal life support (ECLS) in adults remains controversial. Ongoing clinical trials and research have shown a benefit for its use to salvage severe ARDS patients that are in failure with conventional treatment. We encountered a 41-year-old woman who developed ARDS induced by pneumococcal pneumonia. Despite conventional mechanical ventilation in the emergency room, severe hypoxia remained. We treated the patient immediately with ECLS. The patient has almost fully recovered, and was discharged from a 177-day stay at our hospital.Keywords:
Life support
Extracorporeal
Extracorporeal life support (ECLS) is used to support patients with pulmonary alveolar proteinosis (PAP) both during acute illness and during lung lavage therapies. We report the challenges encountered while providing ECLS for respiratory failure to a 12-year-old girl with PAP who had previously received ECLS as a toddler for a prior episode of respiratory failure due to PAP. She was placed on venovenous-arterial (VVA) ECLS and subsequently switched to venovenous (VV) ECLS with drainage from the right femoral vein and reinfusion by a long cannula placed into the right atrium. Our case illustrates standard cannulation may not be possible for children requiring a second ECLS course and the importance of considering alternative modes of cannulation and ECLS support when conventional methods are not possible.
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The incidence of acute respiratory distress syndrome (ARDS) has been estimated worldwide to range from 1.7 to 75 cases per 100,000. There are many treatments for ARDS, but only the low tidal volume strategy is based on strong clinical evidence from randomized clinical trials. The efficacy of extracorporeal life support (ECLS) in adults remains controversial. Ongoing clinical trials and research have shown a benefit for its use to salvage severe ARDS patients that are in failure with conventional treatment. We encountered a 41-year-old woman who developed ARDS induced by pneumococcal pneumonia. Despite conventional mechanical ventilation in the emergency room, severe hypoxia remained. We treated the patient immediately with ECLS. The patient has almost fully recovered, and was discharged from a 177-day stay at our hospital.
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In this article, summary data from the annual international Extracorporeal Life Support Organization (ELSO) Registry Reports through July 2012 are presented. Nearly 51,000 patients have received extracorporeal life support (ECLS). Of the patients, 50% (>25,000) were neonatal respiratory failure, with a 75% overall survival to discharge or transfer. Congenital diaphragmatic hernia remains a major use of ECLS in this population with 51% survival. Extracorporeal life support use for pediatric respiratory failure has nearly doubled since 2000, with approximately 350 patients treated per year in the past 3 years examined (56% survival). Previously stable at about 100 cases a year for a decade, adult respiratory failure ECLS cases increased dramatically in 2009 with the H1N1 influenza pandemic and publication of the Conventional ventilation or ECMO for Severe Adult Respiratory failure (CESAR) trial results and have remained at approximately 400 cases a year through 2011 (55% survival). Use of ECLS for cardiac support represents a large area of consistent growth. Approximately 13,000 patients have been treated with survival to discharge rates of 40%, 49%, and 39% for neonates, pediatric, and adults, respectively.
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Purpose of the Study. This report presents the experience with one case of status asthmaticus who failed to respond to mechanical ventilation and was successfully managed with extracorporeal life support (ECLS) using venovenous bypass. The purpose is to inform the practitioner of an additional therapy, potentially of benefit, in management of asthma complicated by treatment-resistant respiratory failure. Methods. Low volume venovenous bypass with extracorporeal life support resolved severe respiratory failure in a 23-year-old female asthmatic over a 22-hour period after failure of 5 hours of mechanical ventilation. Bypass was initiated remotely by an ECLS team using a portable ECLS circuit before the 180-mile transport to the "nearby" center. Details of the technique are presented. Conclusion and Reviewer's Comments. This may be the first instance where asthma was the primary indication for ECLS; other asthmatics have been so treated, but for other complicating conditions like pneumonia and adult respiratory distress syndrome. This report provides a further alternative therapy, even in somewhat remote areas, for asthma-caused respiratory failure.
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In this article, data from the annual international Extracorporeal Life Support Organization (ELSO) Registry Reports through July 2004 are presented. Nearly 29,000 patients have received extracorporeal life support (ECLS). Of the patients, 66% (more than 19,000) were neonatal respiratory failure, with a 77% overall survival to discharge or transfer. The number of neonatal respiratory cases reported to the Registry has decreased from a peak of 1,500 patients in 1992 and has leveled off at approximately 800 cases per year. The number of pediatric respiratory cases has remained at approximately 200 cases per year since 1993, with a 56% survival to discharge or transfer. Adult respiratory failure continues to be the smallest age group treated with extracorporeal membrane oxygenation (ECMO), with less than 100 cases per year. Survival to discharge, however, is comparable with pediatric respiratory failure (53%). Support continues to increase for cardiac failure across all age groups, with survival to discharge rates of 38%, 43%, and 33% for neonatal, pediatric, and adults, respectively. Survival in pediatric and adult respiratory failure cases supported with ECLS has remained fairly consistent over the past 5 years.
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To investigate the relationship between the period of mechanical ventilation before extracorporeal life support and survival in patients with respiratory failure.Retrospective review.Surgical intensive care unit at a university medical center.Thirty-six consecutive adult patients with severe respiratory failure managed with extracorporeal life support.Extracorporeal life support was utilized in 36 acute respiratory failure adult patients with a variety of diagnoses and an estimated mortality rate of > 90%. Management protocols were followed before and during extracorporeal life support. The 36 patients were physiologically similar before extracorporeal life support was initiated: shunt of 48 +/- 17%; F10(2) of 1.0 +/- 0.1; peak inspiratory pressure of 56 +/- 16 cm H2O; positive end-expiratory pressure of 14 +/- 6 cm H2O; and respiratory rate of 23 +/- 10 breaths/ min. Ventilation was utilized for 1 to 17 days before extracorporeal life support. Typical lung rest settings during extracorporeal life support were F10(2) of 0.40, peak inspiratory pressure of 30 cm H2O, positive end-expiratory pressure of 10 cm H2O, and respiratory rate of 6 breaths/min. Death was almost always secondary to end-stage pulmonary failure.Survival (hospital discharge) in these 36 patients was inversely associated with the number of days of preextracorporeal life support ventilation, with a 50% mortality rate predicted by logistic regression after 5 days of mechanical ventilation. The overall survival rate was 18 (50.0%) of 36 patients.In severe acute respiratory failure treated with lung rest and extracorporeal life support, a predicted 50% mortality rate was associated with 5 days of preextracorporeal life support mechanical ventilation.
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Objectives The purposes of this report are to a) describe the University of Michigan experience with venoarterial or venovenous extracorporeal life support for severe pediatric pulmonary rescue therapy, and b) examine survivors and nonsurvivors for differences that might be useful for examination in future, prospective studies. Design Case series report. Phase I study of safety and effectiveness of extracorporeal life support for pediatric respiratory failure. Setting University of Michigan Medical Center. Patients Non-neonatal pediatric patients treated with extracorporeal life support for severe respiratory failure at the University of Michigan. Interventions Extracorporeal life support for pulmonary failure. Measurements and Main Results From November 1982 until May 1991, 25 pediatric patients underwent extracorporeal life support for severe pulmonary failure. Twenty patients were treated in the last 36 months. Sixty percent (15/25 patients) survived their life-threatening respiratory illness, were weaned from mechanical ventilation, and were discharged home. The mean patient age was 4.1 yrs, and mechanical ventilation duration before extracorporeal life support was 5.9 days. Mean blood gas data and mechanical ventilation pressures before extracorporeal life support were: peak inspiratory pressure of 48.6 cm H2O, mean airway pressure of 21.9 cm H2O, positive end-expiratory pressure of 9.7 cm H2O, PaCO2 of 43 torr (5.7 kPa), PaO2 of 69 torr (9.1 kPa), estimated alveolar-arterial oxygen gradient of 563 torr (75 kPa), and FIO2 of 0.98. Variables associated with survival included: age of survivors vs. nonsurvivors, 2.1 vs. 7.1 yrs (p < .02); peak inspiratory pressure of survivors vs. nonsurvivors, 43.1 vs. 57.9 cm H2O (p < .03); mean airway pressure of survivors vs. nonsurvivors, 18.4 vs. 27.2 cm H2O (p < .03); and positive end-expiratory pressure of survivors vs. nonsurvivors, 8.1 vs. 12.1 cm H2O (p < .01). There were no differences detectable in the blood gas values (PaO2, PaCO2, P[A-a]O2) in survivors and nonsurvivors before extracorporeal life support. The number of days mechanical ventilation was used before extracorporeal life support in survivors and in nonsurvivors was similar. Conclusion Extracorporeal life support is an effective rescue therapy for pediatric patients with severe respiratory failure (University of Michigan survival rate of 60%). (Crit Care Med 1992; 20:1112–1118)
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Diffuse alveolar hemorrhage secondary to systemic lupus erythematosus (SLE) may cause life-threatening respiratory failure and may be associated with multiple organ failure. Extensive support may be necessary to sustain life while systemic therapy becomes effective. We report here a patient with profound respiratory failure secondary to SLE associated with multiorgan failure, who was supported with veno-arterial extracorporeal lung assist (ECLA), veno-venous ECLA, and multiple continuous renal replacement therapies during plasmapheresis. The full spectrum of extracorporeal life support and treatment modalities was performed seamlessly by a single service within the critical care department.
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