ECMO Beneficial in Extreme Cases of COVID-19 Respiratory Failure

By Will Boggs MD

August 12, 2020

NEW YORK (Reuters Health) - Extracorporeal membrane oxygenation (ECMO) allows early extubation of patients with COVID-19 who have severe respiratory failure, according to a retrospective study.

"We demonstrate that patients can be freed from sedation and mechanical ventilation while well supported on ECMO to allow the lungs to recover," Dr. Antone J. Tatooles from Advocate Christ Medical Center, Oak Lawn and Rush University Medical Center, Chicago, Illinois told Reuters Health by email.

ECMO has proven useful for treating acute respiratory distress syndrome (ARDS), but its use has not been well documented in patients with COVID-19 for whom mechanical ventilatory support is insufficient.

Dr. Tatooles and colleagues treated 40 such patients, ages 22 to 64, with single-access, dual-stage, veno-venous ECMO, according to a report in JAMA Surgery.

All 40 had considerably elevated levels of inflammatory markers, including D-dimer and ferritin, prior to ECMO use.

The mean time from intubation to ECMO was 4.0 days. All patients were subsequently able to discontinue ventilatory support, with a mean interval of 13.0 days from ECMO initiation to extubation.

Most patients (32/40) no longer required ECMO care, and 29 patients were discharged from the hospital without supplementary oxygen.

Ten patients required reintubation, but all have since been extubated. Overall mortality was 15% (6 patients).

Complications were minimal, with no ischemic strokes, inotropic support, or tracheostomies. All patients received systemic anticoagulation as part of their therapy.

"Our early results suggest that patients who have failed ventilatory support and have primary respiratory disease are likely to benefit from our method of ECMO," Dr. Tatooles said. "Additional studies are required to better identify who is best suited for ECMO."

He added, "The dedication of our nurses, specialized allied health professionals, and physicians is critical to the success of this therapy."

Dr. Yuan Shi from Children's Hospital of Chongqing Medical University in China, who recently reviewed the role of ECMO in the treatment of COVID-19, told Reuters Health by email, "According to our experiences and the data from different studies, ECMO should be initiated for those patients who may have a good prognosis and lung recovery."

"In this report, the ages of patients on ECMO ranged from 22 to 64 years old, which may indicate those who were younger receive a better prognosis," he said.

"For ICU physicians, when faced with patients with severe ARDS caused by COVID-19, ECMO is still a rescue therapy," Dr. Shi said. "If possible, single-access, dual-stage cannula would be a better choice for initiation. However, when patients show any symptoms of left heart failure, it is better to change the mode from veno-venous (VV) to veno-arterial (VA) mode."

Dr. Silvio A. Namendys-Silva from Hospital Medica Sur, Mexico City, who recently reviewed the use of ECMO as rescue therapy for ARDS due to COVID-19, told Reuters Health by email, "The results of this report suggest that venovenous ECMO may have a place in the treatment of patients with severe ARDS due to COVID-19."

"For now, clinicians should reserve ECMO for critically ill patients with severe COVID-19 whose life-threatening hypoxemia persists despite conventional low tidal volume ventilation or other strictly studied adjunctive therapies, for example, early application of prone positioning," he said.

"Although the decline in severe COVID 19-related mortality (in patients) treated with venovenous ECMO is welcome, the complexity of ECMO requires a well-qualified intensive care unit team...and it is not available in many low-and-middle income countries around the world," Dr. Namendys-Silva said.

SOURCE: JAMA Surgery, online August 11, 2020.


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