Extracorporeal life support for acute respiratory distress syndrome

Abstract

The morbidity and mortality of acute respiratory distress syndrome remain to be high. Over the last 50 years, the clinical management of these patients has undergone vast changes. Significant improvement in the care of these patients involves the development of mechanical ventilation strategies, but the benefits of these strategies remain controversial. With a growing trend of extracorporeal support for critically ill patients, we provide a historical review of extracorporeal membrane oxygenation (ECMO) including its failures and successes as well as discussing extracorporeal devices now available or nearly accessible while examining current clinical indications and trends of ECMO in respiratory failure.

Full text

Annals of Thoracic Medicine - Vol 8, Issue 3, July-September 2013 133
Review Article
Extracorporeal life support for acute
respiratory distress syndrome
Don Hayes Jr.1,4-6, Joseph D. Tobias2,4,7, Jasleen Kukreja9, Thomas J. Preston4,
Andrew R. Yates3-5, Stephen Kirkby1,4-6, Bryan A. Whitson8
Abstract:
The morbidity and mortality of acute respiratory distress syndrome remain to be high. Over the last 50 years, the
clinical management of these patients has undergone vast changes. Signicant improvement in the care of these
patients involves the development of mechanical ventilation strategies, but the benets of these strategies remain
controversial. With a growing trend of extracorporeal support for critically ill patients, we provide a historical review
of extracorporeal membrane oxygenation (ECMO) including its failures and successes as well as discussing
extracorporeal devices now available or nearly accessible while examining current clinical indications and trends
of ECMO in respiratory failure.
Key words:
Acute respiratory distress syndrome, extracorporeal life support, extracorporeal membrane oxygenation
The initial mortality rates associated with acute
respiratory distress syndrome (ARDS) were
reported to be as high as 50% in 1967.[1] Published
studies in the early 1990s demonstrated a
reduction in mortality that continued to a
nadir of 29‑38% by the end of the decade.[2‑6]
More recently, the mortality associated with
ARDS has remained steady at 25‑30%.[7,8] In
a recent study, there was no difference in
mortality rates between early‑ and late‑onset
ARDS.[9] Although this reduction in ARDS
mortality is not universally accepted, there has
been some progress in the treatment of acute lung
injury (ALI) and ARDS. This progress is directly
related to the methods of respiratory support
employed in the treatment of critically ill patients
with ARDS. In this manuscript, we review the
changes in conventional mechanical ventilation
before moving onto methods of extracorporeal
support. We discuss early failures and more
recent success of extracorporeal membrane
oxygenation (ECMO), while discussing
alternative extracorporeal devices currently
available or soon to be accessible. To conclude,
we briey discuss the current clinical applications
and recent trends for the use of ECMO.
Conventional Respiratory Support for
Acute Respiratory Distress Syndrome
Typically, therapeutic strategies hinge on the
knowledge of the underlying disease process,
but our understanding of ARDS is very limited.
Despite our limited understanding of the
pathophysiology, numerous clinical trials,
including the ARDS network trial, suggested
that specic ventilator management techniques
could lead to superior outcomes.[10] Lung
protective ventilation with adjusted positive
end‑expiratory pressure (PEEP) remains the
most effective respiratory support method. It
is now clear that high tidal volumes result in
further lung injury and that the use of lower tidal
volumes (6 ml/kg) may improve mortality.[10‑14]
Mechanical ventilation with lower tidal volumes,
resulting in higher than normal CO2 partial
pressures (permissive hypercapnia), is associated
with not only a reduction in mortality but also
a less number of days requiring ventilator use.
The complications and mortality of severe lung
injury and ARDS remain very high at 35‑45%.[15]
A major reason for the slow progress in
advancement of the treatment of ALI and
ARDS is the lack of detailed knowledge of the
pathophysiology of ARDS and the impact upon
this physiology by the current treatment strategies.
The current trend of permissive hypercapnia is
constrained by the limits of tolerable respiratory
acidosis which may cause substantial changes
in hemodynamic function and organ blood ow
unless the arterial pH is controlled.[16,17]
In refractory ARDS with profound
hypoxemia or respiratory acidosis, additional
non‑pharmacological interventions are
necessitated, such as positioning maneuvers,
nitric oxide, reverse inspiratory:expiratory ratio
ventilation strategies, airway pressure ventilation,
partial liquid ventilation, or high‑frequency
ventilation techniques. Additionally, the use of
extracorporeal support is now starting to be used
more commonly. Extracorporeal technology may
benet this patient population by facilitating
Address for
correspondence:
Dr. Don Hayes,
Jr. The Ohio
State University,
Nationwide Children’s
Hospital, 700 Children’s Drive,
Columbus, OH 43205, USA.
E-mail: hayes.705@osu.
edu
Submitted: 10-10-2012
Accepted: 10-10-2012
1Section of
Pulmonary Medicine,
2Anesthesiology,
and 3Cardiology,
Nationwide Children’s
Hospital, 4Heart
Center, Nationwide
Children’s Hospital,
Departments of
5Pediatrics,
6Internal Medicine,
7Anesthesiology,
and 8Surgery,
The Ohio State
University Wexner
Medical Center,
Columbus, OH,
9Department of Surgery,
University of California
at San Francisco
Medical Center, San
Francisco, CA, USA
Access this article online
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Website:
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DOI:
10.4103/1817-1737.114290
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Hayes, et al.: ELS for ARDS
134 Annals of Thoracic Medicine - Vol 8, Issue 3, July-September 2013
gas exchange without the harm associated with aggressive
mechanical ventilation. Extracorporeal life support is a
modied form of cardiopulmonary bypass used to provide
prolonged gas exchange in patients with respiratory and/or
cardiac failure. The devices require fairly large cannulas for
continuous pumping of blood from the patient to a membrane
oxygenator. In addition to oxygenation, CO2 can be efciently
removed with extracorporeal technology. A major limitation
of this complicated form of intensive care is the need for
anticoagulation to prevent blood clotting.
Extracorporeal membrane oxygenation in ARDS
In 1972, Hill et al. published the rst case report that used ECMO
in a patient who suffered from ARDS due to acute post‑traumatic
respiratory failure. At that time, mortality rates from ARDS were
exceedingly high, and the idea of extracorporeal support in this
population showed great promise.[18] However, a randomized
controlled trial using ECMO in ARDS demonstrated mortality
rates of>90% in both treatment arms.[19] Although this was a
landmark paper by Zapol et al.[19] at that time, it suffered from
signicant aws, including the use of only veno‑arterial (VA)
ECMO, termination of ECMO after 5 days was an option if no
improvement occurred, signicant problems with bleeding, the
lack of “rest” ventilator settings, and the lack of experience of
many participating centers. Despite these dismal results, several
investigators continued to work in the area of extracorporeal
devices and strategies. Extracorporeal CO2 removal paired
with a novel ventilation strategy at that time, low‑frequency
positive pressure mechanical ventilation, demonstrated
some improvement in results.[20‑23] However, a randomized
controlled trial failed to demonstrate an actual survival benet
from extracorporeal CO2 removal in ARDS, although the
survival rates were substantially improved as compared to the
1970s.[24] Survival rates were 33% for the extracorporeal group
and 42% for the conventional mechanical ventilation group.[24]
The investigators were unable to show a survival benet as
the cohort study was small (n=40) compared to the ARDS
network trial on low tidal volumes that stopped recruitment
after enrolling 861 patients.
Early poor outcomes with extracorporeal membrane
oxygenation in ARDS
The lack of any substantial impact upon mortality in these
early studies with extracorporeal CO2 removal in ARDS is
multifactorial. Early extracorporeal CO2 devices were limited
in their technology. In addition, ventilation strategies differed
substantially at that time compared to today where low tidal
volumes and airway pressure gradients are now used for
protective ventilation.[10,11,25,26]
Extracorporeal devices continue to be used more frequently
than ever before in intensive care units throughout the world.
With advancements in technology, the new devices are less
prone to complications. In addition to technological progress,
there has been improvement related to the clinical application
of extracorporeal support devices in individual patients,
including early introduction and strategies for changing from
devices as clinically indicated.[27,28]
Recent outcomes with ECMO in ARDS
The recent report of successful ECMO support in older
patients inicted with H1N1 inuenza increased interests in
the use of this mode of support in adult patients with severe
respiratory failure.[29] Also that same year, the conventional
ventilatory support versus ECMO for severe adult respiratory
failure (CESAR) study was published. The investigators
used a “pragmatic” study design and were criticized for the
inability to standardize mechanical ventilation management in
the conventional care group.[30] Importantly, the CESAR trial
demonstrated that protocolized care that included ECMO in an
expert center for ARDS care yielded higher survival than the
best standard care in tertiary intensive care units in the UK.[30]
Innovations in ECMO
In the 1960s, a milestone in the technological evolution of ECMO
was the development of membrane oxygenators, which began
replacing bubble oxygenators. Membrane oxygenators provided
gas exchange with the benets of increased short‑ and long‑term
biocompatibility. The recently developed membrane‑type
oxygenators were less harmful as blood was exposed to oxygen
through a gas‑permeable membrane, which enhanced gas transfer
compared to the bubble oxygenators. At the end of the 1990s, a
silicone covering of the microporous polypropylene hollow
bers was used that had a heat exchanger and oxygenating
compartment with a polymethylpentene (PMP) membrane in a
small polycarbonate shell.[31] Development of the PMP oxygenator
has proven to be an important advancement in ECMO technology
as the PMP oxygenators have slowly replaced both the silicone
membrane and polypropylene microporous oxygenators.[32,33]
The PMP oxygenators result in a reduction of the need for red
blood cell and platelet transfusions, provide better gas exchange,
have lower resistance and priming volumes compared to silicone
membrane oxygenators, and have less oxygenator failure
compared to polypropylene microporous oxygenators.[34] The
development of heparin‑coated circuits allows for extracorporeal
support with decreased platelet, complement, and granulocyte
activation with reduced heparin requirements.[35,36] New
generation centrifugal pumps permit support with essentially
no risk of tubing rupture with a smaller priming volume
and potentially reduced need for a reservoir.[37] Yet, another
major innovation that has truly enhanced the capability of
extracorporeal CO2 removal was the development of a bicaval
dual‑lumen catheter (Avalon Laboratories, Rancho Dominguez,
CA, USA) that allows respiratory support through a single
catheter for application of ECMO.[38]
Different modes of ECMO
In the setting of complete cardiopulmonary support,
conventional VA ECMO is primarily used while primary
respiratory failure, including severe oxygenation failure,
is treated with veno‑venous (VV) ECMO. Hypercapnic
respiratory failure can be treated with either a VV or a VA
approach. Both VV and VA approaches require a pump that
is capable of generating ow rates of 3‑5 l/min to assure
sufcient organ perfusion and oxygenation in the adult size
patient. Figure 1 illustrates the different cannulation strategies
for the variable forms of ECMO support (VA, VV, and double
lumen VV) currently used in patients. An arterio‑venous (AV)
approach can be used as well which does not require a pump.
In specic circumstances, low‑resistance devices can be used
which allow sufcient blood ow driven by the systemic blood
pressure from the patient. These pumpless extracorporeal lung
assist (PECLA) devices achieve ow rates of 0.8‑1.5 l/min
allowing for sufcient CO2 removal.
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Hayes, et al.: ELS for ARDS
Annals of Thoracic Medicine - Vol 8, Issue 3, July-September 2013 135
Alternative extracorporeal devices
Arterio‑venous CO2 removal
An AV shunt for extracorporeal gas exchange can potentially
reduce the complexity of conventional ECMO, while allowing
for gas exchange to achieve near total removal of CO2. The
technique of extracorporeal AV CO2 removal (AVCO2R) was
developed using a low‑resistance, commercially available,
hollow ber gas exchanger to provide lung rest in the setting
of severe respiratory failure.[39] Although AVCO2R is efcient
in CO2 removal, it does not provide any substantial oxygen
transfer. The initial human study with AVCO2R included ve
adult patients with ARDS and CO2 retention with percutaneous
AVCO2R achieving approximately 70% CO2 removal in the
cohort without hemodynamic compromise or instability, while
oxygenation was successfully managed with gentle ventilation
and near‑apneic oxygenation.[40] All of these patients survived
the study period without adverse sequelae and only minor
complications.[40]
PECLA, Novalung®, and interventional lung assist (used
interchangeably)
The early success of AVCO2R intensified the interest
and increased the use of AVCO2R in Europe, which is
termed PECLA, interventional lung assist (ILA) device, or
Novalung® (Novalung GmbH, Talheim, Germany). These
devices have a circuit that uses a hollow ber gas exchanger
without the need for a pump.
An in vivo study with an ovine model was undertaken
to determine the efcacy of the Novalung® circuits in the
short‑term removal of CO2 and to assess hemodynamic
responses.[41] The animal was cannulated in the jugular vein
and carotid artery for 72 h.[41] The Novalung® device provided
near total CO2 removal (mean: 119.3 ml/min) with device blood
ow rates (Qb), 1 l/min; sweep gas ow rates (Qg), 5 l/min;
and PaCO2, 40‑50 mmHg.[41] The PaCO2 level was also found to
be directly proportional to the CO2 clearance for the device.[41]
In another in vivo study with a pig model, ILA was studied
to determine the device’s ability to improve oxygenation
with cannulation through both femoral arteries and one
femoral vein with the animals anesthetized and mechanically
ventilated.[42] With the application of ILA, the arterial partial
pressure of oxygen was increased from 64 ± 13 mmHg to
71± 14 mmHg and 74±17 mmHg with blood ow through
one and two femoral arteries, respectively.[42] The increase in
oxygenation was small, but was signicant; thus, the results
indicated that ILA may not be warranted if oxygenation is the
primary therapeutic goal.[42] Two further studies demonstrated
that the Novalung® device provided adequate gas exchange
without hemodynamic instability with static ventilation at
PEEP pressures≥10 cm H2O.[43,44] A third animal study, using
an ARDS model, was performed to prospectively evaluate
the effects of ILA on hemodynamics and gas exchange in
cardiopulmonary resuscitation.[45] Ventricular brillation was
induced in the lung injured, mechanically ventilated pig with
chest compressions starting immediately and continuing
for 30 min in the anesthetized animals.[45] The experimental
group (open ILA system) showed a marked decrease in
PaCO2 and increase in PaO2 without a signicant difference
in systolic and mean blood pressure compared to the control
group (clamped ILA system).[45]
The Novalung® system has been investigated in Europe since
1996 and has been established as a therapeutic measure for
a variety of lung conditions. In one study, the Novalung®
was used easily and inexpensively used in 1,800 patients for
articial lung assistance.[46] Furthermore, the PECLA device
was effective at oxygenation and CO2 removal in 70 patients
with severe respiratory failure of various etiologies.[47] A
10‑year‑review outlined experience in 159 patients ranging
in age from 7 to 78 years who were treated with PECLA for
ARDS (70.4%) and pneumonia (28.3%).[48] The study had a
cumulative experience of over 1,300 days.[48] During the study
period, the overall mortality was 48.7%, mostly attributed to
multiorgan failure.[48] Inability to stabilize pulmonary function
was noted in only 3% of patients, and the 30‑day mortality after
PECLA was 13.6%.[48] Numerous case reports, retrospective
analyses, and prospective studies have validated the PECLA
for use as a therapeutic measure for CO2 removal in a wide
variety of etiologies of acute respiratory failure including
ARDS[49‑67] and as a bridge to lung transplantation.[52‑56] The
PECLA system has been proven to be superior to lung assist
devices that require a pump because it signicantly reduces
bleeding, hemolysis, and mechanical trauma to the blood.
Figure 1: Three congurations of extracorporeal blood ow (a) single-site double lumen veno-venous (VV), (b) two-site VV, and (c) veno-arterial
c
b
a
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Hayes, et al.: ELS for ARDS
136 Annals of Thoracic Medicine - Vol 8, Issue 3, July-September 2013
A multitude of studies have demonstrated that the Novalung®
facilitates the reversal of hypercapnia, while stabilizing
oxygenation with the only reported complication being
reversible distal limb ischemia.[68‑80] In a large cohort study
with 96 patients with severe ARDS, the application of ILA
signicantly increased the PaO2/FiO2 ratio, while improving the
PaCO2 and pH within 2 h in all patients.[81] The ILA eliminated
approximately 50% of calculated total CO2 produced with rapid
normalization of respiratory acidosis.[81]
Despite extensive study, the main disadvantages of ILA
are arterial damage, immobilization, and cardiovascular
steal. Therefore, newer technology was needed and has
continued to evolve with the most device released being ILA
activve® (Novalung GmbH, Talheim, Germany).
Intravenacaval (intravascular) oxygenator and CO2 removal device
Mortensen developed the concept of an intravenacaval
(intravascular) oxygenator and CO2 removal device (IVOX)
as an intracorporeal gas exchange device in patients with
ARDS.[82,83] The components of IVOX include multiple hollow
bers, that are silicone coated and heparin bonded, to create
a thin membrane, which are then placed in the vena cava to
provide blood oxygenation and CO2 removal, without the
need for extracorporeal circulation or blood transfusion. The
bers join together in a manifold that communicates with the
dual‑lumen gas conduit at both the proximal and distal ends.
In animal models, implantation of the IVOX device did not
adversely affect hemodynamic function and there was no
evidence of signicant hemolysis, thromboembolism, foaming
in the blood, catheter migration, or vena caval intimal injury.[84‑87]
In the initial design, the IVOX was capable of removing up to
30% of CO2 production in an ovine model (normal: 150‑180 ml/
min) of severe smoke inhalation injury.[84] The IVOX device
was easy to use, but generated somewhat variable results, for
instance when there were changes in cardiac output, instability
in metabolism, or compensation in respiration. The IVOX
device has had limited capacity in comparison to natural
lungs.[87] The IVOX device in animal and human studies has
demonstrated an average of 40 ml/min of CO2 removal and
oxygen exchange, approximately 25‑30% of the metabolic
demands of the patients implanted with the device.[85,86] The
end result was that IVOX could not be recommended as an
alternative for ECMO or provide total support for patients
with acute respiratory failure.
An international multicenter Phase I‑II clinical trial of IVOX
with a total of 164 IVOX devices used in 160 patients with acute
respiratory failure, due to a variety of causes (lung infection,
trauma, sepsis, and ARDS), found an immediate improvement
in blood gas ndings in a majority of patients, which allowed
for a reduction in ventilator settings.[88] The overall survival
of patients who were treated with the IVOX device was only
30% and was directly related to the severity of lung injury and
patient selection. Device complications included mechanical
and/or performance problems and user errors, whereas patient
complications included bleeding, thrombosis, infection, venous
occlusion, and arrhythmias.[88] Due to these experiences with
IVOX, signicant improvements are needed in the design
and engineering of the device in order for it to become more
clinically applicable.
Intravascular lung assist device
The intravascular lung assist device (ILAD) was designed
by placing the membrane bers into sub‑units of rosette‑like
layers, with a surface area of 0.4‑0.6 m2 perpendicular to blood
ow with the same intravascular placement.[89] The device
achieved 100 ml/min of both oxygen and CO2 exchange, but the
blood pressure gradient required to overcome the resistance of
the device to attain this gas exchange was high (23‑105 mmHg).
Further attempts were unsuccessful with the bers in a helical
form.[90] Unlike conventional devices which depend on passive
bulk blood ow around them, this “pumping” ILAD causes an
active driving force for the blood when rotated.
Hattler respiratory assist catheter
The Hattler respiratory assist catheter incorporates a small
pulsating balloon into the middle of a hollow ber bundle.
Functioning characteristics of the device have been studied
in vivo and in vitro studies.[91] The balloon allows for convective
mixing of the blood and thus increases gas exchange. A larger
balloon volume and higher pulsation rate have been shown
to increase both oxygen loading and CO2 removal in a linear
fashion in an in vitro model.[91] In another study, application
of a random balloon pulsation did not signicantly impact gas
exchange within the respiratory assist catheter.[92] Despite these
advances, the clinical use of an intravenous respiratory assist
device is impeded by the insertion diameter of the catheter
due to the catheter being dependent upon the critical number
of hollow ber membranes necessary to achieve gas exchange.
The current catheters being prepared for human clinical
trials require an insertion size of 32 Fr, even with optimal gas
exchange efciency of the pulsating balloon. Therefore, efforts
are moving forward with the development of an impeller
percutaneous respiratory assist catheters (iPRAC) with an
insertion size<25 Fr.[93] The limitation to the clinical application
of this sort of a catheter is the ability to protect the vascular
endothelium from rotating bers.
The latest concept in respiratory assist catheters is the
development of iPRAC. The new design incorporates rotating
impellers within a stationary bundle of hollow ber membranes.
Active mixing by rotating impellers produced 70% higher gas
exchange efciency than pulsating balloon catheters.[94] The
iPRAC catheter has a diameter of 25 Fr and surface area of
0.07 m2 with no adverse effects on hemodynamic function in
laboratory animals. Even though the CO2 removal efciency
of the iPRAC is currently the highest of any respiratory assist
catheter, improvements are still needed before it can be
used as a clinical device. Future studies will need to address
optimal blood ow and gas exchange through the catheter and
long‑term efcacy of CO2 removal while assessing novel hollow
ber membrane coatings to facilitate additional CO2 removal.[94]
Decap and hemolung respiratory assist system®
More recently, the modication of a continuous VV hemodialysis
machine was introduced that solely performs decapneization
(CO2 removal) in conjunction with hemoltration in a system
called DECAP/DECAPsmart (Medica S.p.A., Medolla, Italy).[95]
For intravascular access, a single double lumen cannula is
inserted into the femoral vein with blood ow achieved by
a non‑occlusive roller pump with blood circulating through
a membrane oxygenator then a hemolter. Although this
system does not allow for total gas exchange, it may augment
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Hayes, et al.: ELS for ARDS
Annals of Thoracic Medicine - Vol 8, Issue 3, July-September 2013 137
CO2 removal that would further permit reduction of minute
ventilation. Extracorporeal CO2 removal devices have been
used in a Phase II study supporting the use of this technology
in patients with severe ARDS who fail a trial of protective
ventilation.[96] Similar dialysis‑like systems are inltrating
the market now, including the Hemolung Respiratory Assist
System® (ALung Technologies, Inc., Pittsburgh, PA, USA).
Clinical indications of ECMO
Figure 2 illustrates three key components of an ECMO circuit: The
oxygenator, better bladder (venous compliance chamber) if used,
and bubble detector. The oxygenator facilitates gas exchange
and the better bladder controls pump ow as a function of inlet
pressure, while bubble detection is a vital preventative measure.
Guidelines describing indications and the practice of ECMO are
published by the Extracorporeal Life Support Organization.[97] The
generally accepted criterion for the initiation of ECMO is either
acute severe cardiac or pulmonary failure or combination of both
that is potentially reversible and unresponsive to conventional
management. Examples of these clinical situations include the
following etiologies: Hypoxic respiratory failure with a ratio of
arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2)
<100 mmHg despite optimal settings on mechanical ventilation,
hypercapnic respiratory failure with an arterial pH < 7.20,
refractory cardiogenic shock, cardiac arrest, failure to wean from
cardiopulmonary bypass after cardiac surgery, and as a bridge
to either heart or lung transplantation. Depending on the clinical
situation, ECMO can even be implemented at the bedside of a
patient [Figure 3].
Clinically, VA ECMO provides complete cardiorespiratory
support by extracting blood from the right atrium and returning
it to the arterial system, therefore bypassing the heart and lungs.
Contrasted to a VV approach, blood is extracted with VV
ECMO from the vena cava or right atrium and returned to the
right atrium with the patient still dependent on their intrinsic
biventricular cardiac performance for hemodynamic support.
Characteristically, VA ECMO is used for cardiac or combined
cardiopulmonary failure, and VV ECMO is used for respiratory
failure. The results of VV ECMO support for respiratory failure
are similar to outcomes compared to VA ECMO, but with less
morbidity secondary to improved neurological outcomes and
preservation of arterial blood vessels.[98‑102]
As discussed earlier, the development of a bicaval dual‑lumen
catheter (Avalon Laboratories, Rancho Dominguez, CA,
USA) allows for respiratory support via application of ECMO
through a single catheter site.[38] The catheter is inserted from
the right jugular vein into the superior vena cava, traversing
the right atrium to the inferior vena cava where it drains
venous blood from both the superior and inferior vena cava
and then directs oxygenated blood into the right atrium
toward the tricuspid valve. The single site application of
this method of VV ECMO in the neck permits ambulation
and oral nutrition and has been used in patients as a bridge
awaiting lung transplantation.[103‑106] The theory behind this
methodology of ambulatory ECMO [Figure 4] in patients
with advanced lung disease requiring lung transplantation is
to optimize both physical rehabilitation and nutrition prior to
lung transplantation. To our knowledge, the use of ambulatory
ECMO has not been attempted in ARDS, but the use of a simple
circuit with the capability of total or near‑total gas exchange
should be considered in this population and may be a potential
therapeutic option to liberate ARDS patients from mechanical
ventilation.
Figure 2: An extracorporeal membrane oxygenation circuit with the oxygenator,
better bladder, and bubble detector
Figure 3: Implementation of veno-arterial extracorporeal membrane oxygenation
at the beside of a patient
Figure 4: Ambulatory extracorporeal membrane oxygenation with single-site double
lumen veno-venous approach being used in a patient as a bridge for lung transplantation
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Hayes, et al.: ELS for ARDS
138 Annals of Thoracic Medicine - Vol 8, Issue 3, July-September 2013
Conclusions
Extracorporeal treatment modalities are showing promise
in the management of ARDS and are being increasingly
used in intensive care units as rescue therapies in patients
with ARDS who fail to respond to conventional mechanical
ventilation. Patient selection and timing of the application
of the extracorporeal device continue to be very important
determining factors in the eventual outcome. The technology of
the current devices is slowly evolving into smaller systems and
will likely continue to shrink in size. As the risk of these devices
decreases, their role in ARDS may increase but continues to
not be well dened presently with further research needed in
this patient population.
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How to cite this article: Hayes D, Tobias JD, Kukreja J, Preston TJ,
Yates AR, Kirkby S, et al. Extracorporeal life support for acute
respiratory distress syndrome. Ann Thorac Med 2013;8:133-41.
Source of Support: Nil, Conict of Interest: None declared.
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