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End-stage lung disease and severe acute lung injury are complex entities that remain challenges to manage. Therapies include early institution of mechanical ventilation with positive end-expiratory pressure, permissive hypercapnia, pulmonary vasodilators, and complex fluid regimens. Veno-venous extracorporeal membrane oxygenation is an available tr...
Context in source publication
Context 1
... cannula was connected to a crys- talloid primed ECMO circuit, including a CentriMag pump (Levitronix, Boston, Mass) and Quadrox oxygenator (Maquet Cardiovascular LLC, San Jose, Calif). The system and oxygen tank were mounted to a wheeled intravenous pole to facilitate patient mobility (Figure 2). ...
Citations
... Rehabilitation for patients undergoing ECMO is a relatively new field of study, as the first pioneering rehabilitative experiences were published in the 2010s. [17][18][19][20][21][22] The first consensus document on physiotherapy for this class of patients was published in 2017, providing evidence-based support for rehabilitation professionals. 23 Since then, various studies have explored rehabilitation methods for patients undergoing ECMO, 14,15,[24][25][26][27] while a recent EuroELSO survey was designed to capture modalities and characteristics of the physiotherapeutic treatments currently provided in international ECMO settings. ...
Background and purpose
Current information on the latest rehabilitative practices is limited, with previous reviews only covering data up to October 2021, and some considering only patients on awake ECMO or with COVID-19. This review aims to present a concise overview of the latest findings on rehabilitation and highlight emerging trends for patients undergoing ECMO support.
Methods
This integrative review was conducted by searching the National Library of Medicine – PubMed database. Two different search strings “extracorporeal membrane oxygenation” AND “rehabilitation” and “extracorporeal membrane oxygenation” AND “physiotherapy” were used to search the published literature. Articles that did not describe rehabilitation techniques, editorials, conference proceedings, letters to editor, reviews and research protocols were excluded. Studies conducted on pediatric populations were also excluded. The search process was completed in December 2023.
Results
Thirteen articles were included in the final analysis. Eight hundred and thirty-nine patients aged between 27 and 63 years were included; 428 were men (51%). In 31% of the included studies, patients had COVID-19; nevertheless, rehabilitative activities did not differ from non-COVID-19 patients. In most studies, rehabilitation commenced within the first 48–96 h and consisted of progressive exercise and out-of-bed activities such as sitting, standing and walking.
Conclusion
Current practice focuses on rehabilitative protocols that incorporate exercise routines with progressive intensity, greater emphasis on out-of-bed activities, and a multidisciplinary approach to patient mobilization.
... Although no studies have been completed to date to assess its safety and efficacy in patients with CS, there have been small studies showing safety and feasibility in carefully selected patients, and several case reports have shown success when used as a bridge to cardiac transplant [23,24]. Most of the current understanding and experience with ambulatory ECMO has been in patients in respiratory failure on venovenous (VV) ECMO awaiting lung transplant [21,25]. However, given that ambulatory ECMO is associated with minimized deconditioning, improved rates of return to independent functioning, decreased rates of delirium, and shorter ICU and hospital lengths of stay, it may become more commonplace in the treatment of patients with CS in the future [23,26]. ...
Cardiogenic shock is a critical condition of low cardiac output resulting in insufficient systemic perfusion and end-organ dysfunction. Though significant advances have been achieved in reperfusion therapy and mechanical circulatory support, cardiogenic shock continues to be a life-threatening condition associated with a high rate of complications and excessively high patient mortality, reported to be between 35% and 50%. Extracorporeal membrane oxygenation can provide full cardiopulmonary support, has been increasingly used in the last two decades, and can be used to restore systemic end-organ hypoperfusion. However, a paucity of randomized controlled trials in combination with high complication and mortality rates suggest the need for more research to better define its efficacy, safety, and optimal patient selection. In this review, we provide an updated review on VA-ECMO, with an emphasis on its application in cardiogenic shock, including indications and contraindications, expected hemodynamic and echocardiographic findings, recommendations for weaning, complications, and outcomes. Furthermore, specific emphasis will be devoted to the two published randomized controlled trials recently presented in this setting.
... cannula which facilitated oxygen transfer rate of 100 mL/min at a flow of 2.5 L/min in a spontaneously breathing patient. 2 Novalung (Hechingen, Germany) is an interventional lung assist membrane ventilator facilitating pumpless arteriovenous bypass approach for femoral cannulation in awake patients. It is designed for complete removal of CO 2 in hemodynamically stable patients. ...
... With the rapid growth of ECMO to over 17,000 cases/year (ECLS Registry Report: International Summary, 2021), the broader experience has remained one with bed-restricted and mechanically-ventilated patients. However, studies have demonstrated that the artificial respiration provided by ECMO can be compatible with freedom from adjunctive MV and ambulation and exercise (Garcia et al., 2011;Mangi et al., 2010;Garcia et al., 2010;Broomé et al., 2008;Hoopes et al., 2013;Higashida et al., 2016;Hayes et al., 2014). Nosotti et al. (2013) showed that for patients who are bridged to lung transplantation on ECMO support, survival is significantly higher in those spontaneously breathing when compared to those who are mechanically ventilated (85% vs. 50% at one year). ...
... Nosotti et al. (2013) showed that for patients who are bridged to lung transplantation on ECMO support, survival is significantly higher in those spontaneously breathing when compared to those who are mechanically ventilated (85% vs. 50% at one year). Those in the field, including our group, took one step beyond that with the ambulation of patient awaiting lung transplant while supported on ECMO (Garcia et al., 2011(Garcia et al., , 2010Hoopes et al., 2013). Because compact systems designed for ambulation and rehabilitation did not previously exist, we cobbled together components that were awkwardly strapped to rolling intravenous poles to assist efforts to walk ECMO patients (Garcia et al., 2010). ...
Extracorporeal membrane oxygenation (ECMO) is a modality of life support for patients suffering from respiratory and/or cardiac failure. With the advances in membrane oxygenation and pump technology in the last two decades, ECMO has become safer and more durable for clinical use. Along with its overall use, there has been an increase in patients who require long-term ECMO support; either awaiting lung recovery or transplantation. Many of them are awake, participating in physical rehabilitation, and even ambulating while supported on ECMO. While the broader ECMO experience is applied to bed-restricted and mechanically ventilated patients, contemporary studies demonstrated that the artificial respiration provided by ECMO is compatible with freedom from adjunctive mechanical ventilation, ambulation, and exercise. With this in mind, our group set out to develop a novel ambulatory ECMO system to facilitate ambulation in patients supported on ECMO. This paper gives a brief overview of the development of this system, focusing on the journey from a laboratory concept to approval for clinical use by the Food and Drug Administration.
... Patients who have isolated pulmonary pathology and absence of right ventricular or left ventricular dysfunction, V-V ECMO can provide adequate oxygenation and CO 2 removal, especially when treating non-fibrotic patients. The use of dual lumen catheters make mobilization easier and are ideal if CO 2 removal is the main goal (13). Bridging fibrotic patients can be more difficult as getting oxygenated blood from the right ventricle to the left ventricle becomes harder to achieve as time on ECMO support increases. ...
... During late 2008, we learned from C. W. Hoopes (personal communication) that patients could ambulate while supported on ECMO, and we adopted his lead in 2010. 5 Growing numbers of cases have been reported with durations of support well beyond 3 weeks. The longest reported is of a 7-year-old with a 30% burn and smoke inhalation who recovered near normal pulmonary function after 20 months of ECMO. ...
... 4 Since then, alternative surgical techniques using central or upper body cannulation strategies for VV and venoarterial (VA) ambulatory ECMO have been described. [5][6][7] In a review article, 2 the authors conclude that ambulatory VV-ECMO could be a be safe approach in high-volume centers, and may provide equivalent or superior outcomes compared with prolonged mechanical ventilation in patients awaiting lung transplant. ...
... transplant. 2 This 16-fold increase in pretransplant ECMO utilization has been driven by organ allocation policies that favor sicker patients, 13 success in maintaining awake patients who can participate in physical therapy, 8,14,15 and data showing posttransplant outcomes comparable to patients who do not require mechanical respiratory support 8,10 and superior to patients who receive mechanical ventilation alone in some cohorts. 4,9 Despite increased use of ECMO-BTLT, clinical practice remains variable and data are overall lacking. ...
Extracorporeal membrane oxygenation (ECMO) is a cardiopulmonary technology capable of supporting cardiac and respiratory function in the presence of end-stage lung disease. Initial experiences using ECMO as a bridge to lung transplant (ECMO-BTLT) were characterized by high rates of ECMO-associated complications and poor posttransplant outcomes. More recently, ECMO-BTLT has garnered success in preserving patients' physiologic condition and candidacy prior to lung transplant due to technological advances and improved management. Despite recent growth, clinical practice surrounding use of ECMO-BTLT remains variable, with little data to inform optimal patient selection and management. Although many questions remain, the use of ECMO-BTLT has shown promising outcomes suggesting that ECMO-BTLT can be an effective strategy to ensure that complex and rapidly decompensating patients with end-stage lung disease can be safely transplanted with good outcomes. Further studies are needed to refine and inform practice patterns, management, and lung allocation in this high-risk and fragile patient population.
... The practice of ECLS is actively evolving, as experiences with ambulatory ECLS are being reported (51,52). Ambulatory ECLS may help prevent deconditioning in patients awaiting organs and subsequent transplant, and further research may elicit additional advantages (53,54). ...
Lung transplantation is an established treatment option that can improve quality of life and prolong survival for select patients diagnosed with end-stage lung disease. Given the gaps in organ donation and failures to make effective use of available organs, careful selection of candidates for lung transplant remains one of the most important considerations of the transplant community. Toward this end, we briefly reviewed recent trends in pretransplant evaluation, candidate selection, organ allocation, and organ preservation techniques. Since the latest consensus statement regarding appropriate selection of lung transplant candidates, many advances in the science and practice of lung transplantation have emerged and influenced our perspective of 'contraindications' to transplant. These advances have made it increasingly possible to pursue lung transplant in patients with risk factors for decreased survival-namely, older recipient age, increased body mass index, previous chest surgery, poorer nutritional status, and presence of chronic infection, cardiovascular disease, or extrapulmonary comorbid conditions. Therefore, we reviewed the updated evidence demonstrating the prognostic impact of these risk factors in lung transplant recipients. Lastly, we reviewed the salient evidence for current trends in disease-specific indications for lung transplantation, such as chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis, emphysema due to alpha-1 antitrypsin deficiency, and pulmonary arterial hypertension, among other less common end-stage diseases. Overall, lung transplant remains an exciting field with considerable hope for patients as they experience remarkable improvements in quality of life and survival in the modern era.
... Cohort studies have identified that ambulation while awake on ECMO can be achieved by well-experienced ECMO teams. [19][20][21] This case presented a unique challenge in that clinician interaction needed to be limited to preserve personal protective equipment and limit exposure to highly contagious COVID-19. The ECMO, nursing, and physical therapist teams met daily, identifying which exercise interventions could be performed during routine nursing cares and which activities required the presence of rehabilitation therapy in order to preserve respirator supply. ...
Objective
Mobilization while receiving life support interventions, including mechanical ventilation and extracorporeal membrane oxygenation (ECMO), is a recommended intensive care unit (ICU) intervention to maintain physical function. The purpose of this case report is to describe a novel approach to implementing early mobility interventions for a patient who was pregnant and receiving ECMO while continuing necessary infectious disease precautions because of diagnosed coronavirus disease-19 (COVID-19).
Methods (Case Description)
A 27-year old woman who was pregnant was admitted to the ICU with COVID-19 and rapidly developed acute respiratory failure requiring 9 days of ECMO support. After a physical therapist consultation, the patient was standing at the bedside by hospital day 5 and ambulating by hospital day 9.
Results
The patient safely participated in physical therapy during ICU admission and was discharged to home with outpatient physical therapy follow-up after 14 days of hospitalization.
Conclusion
Early mobility is feasible during ECMO with COVID-19, and active participation in physical therapy, including in-room ambulation, may facilitate discharge to home. Innovative strategies to facilitate routine activity in a patient who is critically ill with COVID-19 require an established and highly trained team with a focus on maintaining function.
Impact
Early mobility while intubated, on ECMO, and infected with COVID-19 is feasible while adhering to infectious disease precautions when it is performed by an experienced interdisciplinary team.
