Adult Extracorporeal Life Support for Acute Respiratory Failure

Abstract

Extracorporeal life support (ECLS) systems are mechanical devices designed to temporarily support the failing heart or lungs. They differ from cardiopulmonary bypass systems used in the operating room for very short-term support during surgery in both their configuration and intent. The term ECMO is often used interchangeably with ECLS, as we will use it here, although it denotes a form of ECLS in which the primary purpose is to provide blood oxygenation. There are two anatomic approaches that are used to implement ECMO: veno-arterial (VA) and veno-venous (VV). Virtually all applications are variations on these (Extracorporeal Life Support Organization, 2014). ECMO is a high-risk and complex therapy that may be considered for the sickest patients with ARF. Potential indications for the use of ECMO include severe ARF from: severe ARDS, status asthmaticus, bridge to lung transplantation. ECMO should be organized at regional and national levels to provide the best care possible in high-volume, dedicated centers, because inappropriate use of ECMO may markedly increase hospital costs and expose individual patients to important risks. Referral to an expert ECMO center, where ECMO is offered as part of a larger management protocol for ARF, may be associated with improved outcomes (Peek et al., 2009). Networks of hospitals at the local, regional or interregional level should be created around each ECMO center located in tertiary referral hospitals. Such networks have been successfully organized in the UK (NHS, 2014), Italy and have been associated with encouraging results for the treatment of the most severe forms of influenza A (H1N1)–associated ARDS (Patroniti et al., 2011). The feasibility of a network-wide system to evaluate the daily capacity for receiving patients receiving ECMO at individual centers was also demonstrated in Germany(Weber-Carstens et al., 2013)and in France (Pham et al., 2013). Organization of ECMO programs on a regional or national level is needed to provide the best, safest, and most efficient care possible to the population. Local, regional, or interregional networks of hospitals with a mobile ECMO team should ideally be created around each ECMO center; such a system has recently successfully been organized in a few countries (NHS, 2014).