Abstract
With the goal of protecting injured lungs and extrapulmonary organs, venovenous extracorporeal membrane oxygenation (VV-ECMO) has been increasingly adopted as a rescue therapy for patients with severe acute respiratory distress syndrome (ARDS) when conventional mechanical ventilation failed to provide effective oxygenation and decarbonation. In recent years, it has become a promising approach to respiratory support for awake, non-intubated, spontaneously breathing patients with respiratory failure, referred to as awake ECMO, to avoid possible detrimental effects associated with intubation, mechanical ventilation, and the adjunctive therapies. However, several complex clinical issues should be taken into consideration when initiating and implementing awake ECMO, such as selecting potential patients who appeared to benefit most; techniques to facilitating cannulation and maintain stable ECMO blood flow; approaches to manage pain, agitation, and delirium; and approaches to monitor and modulate respiratory drive. It is worth mentioning that there had also been some inherent disadvantages and limitations of awake ECMO compared to the conventional combination of ECMO and invasive mechanical ventilation. Here, we review the use of ECMO in awake, spontaneously breathing patients with severe ARDS, highlighting the issues involving bedside clinical practice, detailing some of the technical aspects, and summarizing the initial clinical experience gained over the past years.
Highlights
Invasive mechanical ventilation has been the first-line tool for managing severe acute respiratory distress syndrome (ARDS)
It is interesting that immunocompromised ARDS patients are more likely to be selected for awake ECMO [13, 18], and the possible reasons might be as follows: [1] The immunocompromised state in these patients mainly results from HIV infection, hematological malignancies, the transplantation of solid organs, and autoimmune diseases treated with corticoids and/or immunosuppressive therapy [13, 18, 32]
Crotti et al reported that only 27% (8/30) of ARDS patients could tolerate awake venovenous extracorporeal membrane oxygenation (VV-ECMO) in lieu of mechanical ventilation, and 50% of these patients maintained an unexpectedly high respiratory rate even with an increased ECMO sweep gas flow rate as high as 12–15 L/min [29]
Summary
Invasive mechanical ventilation has been the first-line tool for managing severe acute respiratory distress syndrome (ARDS). It is interesting that immunocompromised ARDS patients are more likely to be selected for awake ECMO [13, 18], and the possible reasons might be as follows: [1] The immunocompromised state in these patients mainly results from HIV infection, hematological malignancies, the transplantation of solid organs, and autoimmune diseases treated with corticoids and/or immunosuppressive therapy [13, 18, 32] These patients are at high risks of opportunistic infections, usually with pathogens such as P. jirovecii and cytomegalovirus, which could lead to moderate or severe respiratory failure but less possibly accompanying sepsis, shock, acute kidney injury, or other extrapulmonary organ disorders [34, 35].
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