Ventilación mecánica en pacientes tratados con membrana de oxigenación extracorpórea (ECMO)

doi:10.1016/j.medin.2016.12.007

Medicina Intensiva

Volume 41, Issue 8, November 2017, Pages 491-496

https://doi.org/10.1016/j.medin.2016.12.007 Get rights and content

Resumen

La ventilación mecánica (VM) es clave en el manejo del síndrome de distrés respiratorio del adulto (SDRA) ya que existe un alto nivel de evidencia de que la ventilación con volúmenes tidales de 6 ml/kg (ventilación protectora) mejora la supervivencia. La oxigenación con membrana extracorpórea (ECMO) veno-venosa es una terapia de rescate en el tratamiento de la insuficiencia respiratoria refractaria que mejora la oxigenación, reduce el CO₂ y facilita la aplicación de VM protectora, reduciendo potencialmente la lesión pulmonar asociada a VM.

Aunque las estrategias ventilatorias en pacientes con SDRA han sido analizadas en numerosos estudios, no existe consenso respecto a cómo ventilar a pacientes con ECMO veno-venosa. El concepto de «lung rest», introducido hace años, carece aún de evidencias para recomendar su uso pero podría promover la recuperación pulmonar y facilitar el destete de la VM.

El objetivo de esta revisión es describir las diferentes estrategias de ventilación en pacientes tratados con ECMO veno-venosa.

Abstract

Mechanical ventilation (MV) is a crucial element in the management of acute respiratory distress syndrome (ARDS), because there is high level evidence that a low tidal volume of 6 ml/kg (protective ventilation) improves survival. In these patients with refractory respiratory insufficiency, venovenous extracorporeal membrane oxygenation (ECMO) can be used. This salvage technique improves oxygenation, promotes CO₂ clearance, and facilitates protective and ultraprotective MV, potentially minimizing ventilation-induced lung injury.

Although numerous trials have investigated different ventilation strategies in patients with ARDS, consensus is lacking on the optimal MV settings during venovenous ECMO. Although the concept of “lung rest” was introduced years ago, there are no evidence-based guidelines on its use in application to MV in patients supported by ECMO. How MV in ECMO patients can promote lung recovery and weaning from ventilation is not clear.

The purpose of this review is to describe the ventilation strategies used during venovenous ECMO in clinical practice.

Section snippets

Introducción

La VM constituye la base del tratamiento de los pacientes afectados de SDRA e insuficiencia respiratoria de otras etiologías. Hasta la fecha, solo el uso de VM con volúmenes bajos y limitación de presión meseta (Pm) ha demostrado una reducción de la mortalidad en estos pacientes¹. En estudios más recientes, la VM en decúbito prono mejoró la supervivencia en pacientes con SDRA grave².

A pesar de los avances tecnológicos que han tenido lugar en los últimos años, la mortalidad del SDRA sigue siendo

Lesión pulmonar inducida por ventilación mecánica

La VILI se produce a 4 niveles. La utilización de elevadas presiones meseta generará barotrauma, la lesión derivada de la ventilación con Vt alto causará volutraumatismo y la activación de determinados procesos inflamatorios en células epiteliales y endoteliales alveolares inducidas por una VM agresiva dará lugar al biotraumatismo. Además, el cierre y la reapertura cíclica de las unidades alveolares generarán atelectraumatismo, definido este como el porcentaje de pulmón colapsado que se abre al

Modo de ventilación mecánica con membrana de oxigenación extracorpórea

No está establecido qué modo de VM debemos utilizar en pacientes tratados con ECMO y no disponemos de ningún estudio comparativo. En la tabla 1 se muestran los diversos modos de ventilar a los pacientes en ECMO VV según las distintas opiniones de expertos.

En un estudio reciente internacional en el que formaron parte 141 centros de 28 países de todos los continentes pertenecientes a la Extracorporeal Life Support Organization (ELSO), la mayoría de ellos (62%) utilizaban modos controlados de VM,

Volumen tidal y presión meseta con membrana de oxigenación extracorpórea

Entre los centros pertenecientes a la ELSO y respecto al Vt utilizado, el 76% de ellos reconocieron que ventilaban a sus pacientes con Vt ≤ 6 ml/kg y un 21% no especificaba ninguna cifra de Vt durante el soporte con ECMO VV¹³. En animales, la reducción del Vt < 4 ml/kg de peso ideal ha demostrado una reducción del edema pulmonar y de la lesión pulmonar²⁶. En el estudio multicéntrico Xtravent, la «ventilación ultraprotectora» con ECCO₂R frente a una ventilación protectora no demostró una reducción

Presión positiva al final de la espiración con membrana de oxigenación extracorpórea

En pacientes con SDRA, la PEEP se aplica para mantener el reclutamiento pulmonar, mejorar la oxigenación y prevenir el VALI (atelectraumatismo con cierre y apertura cíclica alveolar). No obstante, la sobredistensión alveolar y el aumento de la poscarga ventricular derecha son efectos deletéreos del uso indiscriminado de PEEP.

Es controvertido qué nivel de PEEP debemos utilizar en pacientes tratados con ECMO. La reducción del Vt, especialmente cuando hacemos «ventilación ultraprotectora» (Vt < 4

Frecuencia respiratoria en ECMO

Tampoco está establecido qué FR debemos utilizar en pacientes tratados con ECMO. La ELSO recomendaba FR baja (4-5 ciclos/min) para evitar el «estrés» mecánico del pulmón, pero en general el rango está entre 4-30 ciclos/min teniendo en cuenta las diferentes publicaciones15. En general, el ajuste de la FR va orientada al mantenimiento del pH arterial, pero este concepto cambia en un paciente en ECMO VV, donde el mantenimiento del pH arterial y la PaCO₂ depende directamente del flujo de gas en la

Fracción inspiratoria de O2 en pacientes con membrana de oxigenación extracorpórea

Es evidente que para minimizar la VILI debemos reducir la FiO₂ a niveles mínimos, con el objetivo de mantener una SatpO₂ > 80% en ECMO VV³¹ o entre 84-88% según los diferentes grupos35, 37.

Conclusiones

En pacientes con SDRA, la VM con reducción de la Pm ha demostrado una reducción de la mortalidad; no obstante, no existen evidencias, guías ni recomendaciones claras respecto a cómo ventilar a los pacientes en ECMO. La reducción en la driving pressure se ha asociado a una mejoría en la supervivencia hospitalaria en pacientes con SDRA grave tratados con ECMO, de manera que podría recomendarse la monitorización de este parámetro de VM al igual que en los pacientes sin ECMO.

Dado que el sistema

Conflicto de intereses

No hay conflicto de intereses.

Agradecimientos

No existen.

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Cited by (18)

Lung ultrasound score for monitoring the withdrawal of extracorporeal membrane oxygenation on neonatal acute respiratory distress syndrome
2024, Heart and Lung
Extracorporeal membrane oxygenation (ECMO) is considered an efficient and life-saving treatment for neonatal severe acute respiratory distress syndrome (ARDS). Bedside lung ultrasound (LUS) is an attractive and feasible method for evaluating neonatal ARDS.
To evaluate the value of LUS score at veno-arterial (V-A) ECMO withdrawal in neonatal patients with severe acute ARDS.
A retrospective preliminary study was conducted in our cardiac intensive care unit from June 2021 to June 2022. Eight severe ARDS neonates who received V-A ECMO were enroled in this study. LUS was measured daily during ECMO and when weaning off ECMO. The relationships between the LUS score and ECMO parameters (blood flow and the sweep gas of FiO₂) were assessed.
(1) There was a significant improvement in LUS score by ECMO treatment. And, various diagnostic signs of lung ultrasound were detected during ECMO, including pulmonary edema (7 neonates) and lung consolidation (4 neonates), followed by pleural effusion (1 neonate) and bilateral white lung (1 neonate). (2) A total of 12 trials for weaning off ECMO were carried out, of which four failed, but all eight neonates finally succeeded in passing the weaning trial. LUS score of 21 or less was defined as a cut-off value for predicting ECMO weaning success. During ECMO treatment, LUS score was positively correlated with ECMO blood flow (r = 0.866, P < 0.05).
LUS can be used to evaluate the various lung diagnostic signs in ARDS neonatal patients during ECMO treatment, and the LUS score under ECMO treatment decreases over time. The reduction in LUS score is associated with lower ECMO blood flow. LUS score is regarded as a predictor of ECMO weaning success.
Extracorporeal membrane oxygenation (ECMO) and beyond in near fatal asthma: A comprehensive review
2023, Respiratory Medicine
The treatment of choice in severe asthma exacerbations with respiratory failure includes ventilatory support, both invasive and/or non-invasive, along with different kinds of asthma medication. Of note, the rate of mortality of patients with asthma has decreased substantially in recent years mainly due to significant advances in pharmacological treatment and other management strategies. However, the risk of death in patients with severe asthma who require invasive mechanical ventilation has been estimated between 6.5% and 10.3%. When conventional measures fail, rescue strategies, such as extracorporeal membrane oxygenation (ECMO) or extracorporeal CO2 removal (ECCO2R) may need to be implemented. While ECMO does not constitute a definitive treatment per se, it can minimize further ventilator associated lung injury (VALI) and can enable diagnostic-therapeutic maneuvers that cannot be performed without ECMO such as bronchoscopy and transfer for diagnostic imaging. Asthma is one of the diseases that is associated with excellent outcomes for patients with refractory respiratory failure requiring ECMO support, as shown by the Extracorporeal Life Support Organization (ELSO) registry. Moreover, in such situations, the use of ECCO2R for rescue has been described and utilized in both children and adults and is more widely spread in different hospitals than ECMO. In this article, we aim to review the evidence for the usefulness of extracorporeal respiratory support measures in the management of severe asthma exacerbations that lead to respiratory failure.
Adjuvant treatments to invasive mechanical ventilation in the management of acute respiratory distress syndrome secondary to COVID-19
2023, Enfermeria Intensiva
La presente revisión bibliográfica está realizada con el fin de obtener respuestas acerca de aspectos relacionados con las técnicas y tratamientos, así como cuidados asociados al paciente crítico diagnosticado con covid-19.
Analizar la evidencia científica disponible sobre la efectividad de la utilización de la ventilación mecánica invasiva junto con otras técnicas coadyuvantes, en la reducción de la tasa de mortalidad en pacientes con síndrome de distrés respiratorio agudo y juicio clínico de covid-19 atendidos en unidades de cuidados intensivos.
Se realizó una revisión bibliográfica sistematizada en las bases de datos PubMed, CUIDEN, LILACS, Medline, CINAHL y Google Scholar, utilizando términos MeSH (adult respiratory distress syndrome, mechanical ventilation, prone position, nitric oxide, extracorporeal membrane oxygenation, nursing care) y los operadores booleanos correspondientes. Los estudios seleccionados se sometieron a una lectura crítica realizada entre el 6 de diciembre de 2020 y el 27 de marzo de 2021 utilizando la herramienta Critical Appraisal Skills Programme en español y un instrumento de evaluación de estudios epidemiológicos transversales.
Se seleccionaron un total de 85 artículos. Tras realizar la lectura crítica se incluyeron en la revisión un total de 7 artículos, consistiendo en 6 estudios descriptivos y un estudio de cohortes. Tras el análisis de dichos estudios, se desprende que la técnica que mejor resultados ha obtenido es la oxigenación por membrana extracorpórea, siendo importantes los cuidados proporcionados por el personal de enfermería cualificado y capacitado.
La mortalidad por covid-19 aumenta en pacientes tratados con ventilación mecánica invasiva respecto a los pacientes tratados con oxigenación por membrana extracorpórea. Los cuidados de enfermería y la especialización pueden repercutir en una mejora de los resultados en los pacientes.
This bibliographic review is carried out in order to obtain answers about aspects related to techniques and treatments, as well as care associated with the critically ill patient diagnosed with COVID-19.
To analyze the available scientific evidence on the effectiveness of the use of invasive mechanical ventilation together with other adjuvant techniques, in reducing the mortality rate in patients with acute respiratory distress syndrome and clinical trial of COVID-19 treated in intensive care units.
A systematized bibliographic review was carried out in the PubMed, CUIDEN, LILACS, Medline, CINAHL and Google Scholar databases, using MeSH terms (adult respiratory distress syndrome, mechanical ventilation, prone position, nitric oxide, extracorporeal membrane oxygenation, nursing care) and the corresponding Boolean operators. The selected studies underwent a critical reading carried out between December 6, 2020 and March 27, 2021 using the Critical Appraisal Skills Program tool in Spanish and a cross-sectional epidemiological studies evaluation instrument.
A total of 85 articles were selected. After performing the critical reading, a total of 7 articles were included in the review, 6 being descriptive studies and one a cohort study. After analyzing these studies, it appears that the technique that has obtained the best results is extracorporeal membrane oxygenation, with the care provided by qualified and trained nursing staff being very important.
Mortality from COVID-19 increases in patients treated with invasive mechanical ventilation compared to patients treated with extracorporeal membrane oxygenation. Nursing care and specialization can have an impact on improving patient outcomes.
Ivermectin contributes to attenuating the severity of acute lung injury in mice
2022, Biomedicine and Pharmacotherapy
Citation Excerpt :
Acute lung injury (ALI) is a common clinical critical disease caused by some non-cardiogenic direct or indirect pulmonary and extrapulmonary factors that progresses to acute respiratory distress syndrome (ARDS) [1,2]. ALI/ARDS has a rapid progression, high disability rate, high mortality rate, and poor prognosis [3,4]. Every year, 80 out of every 100,000 Americans suffer from ALI, and when it progresses to the more severe stage of ARDS, the mortality rate rises to 40 % [5].
Ivermectin has been proposed as a potential anti-inflammatory drug in addition to its antiparasitic activity. Here we investigated the potential role of ivermectin in the pathogenesis of acute lung injury (ALI) using the lipopolysaccharide (LPS)- or bleomycin (BLM)-induced mice models. Male C57BL/6 mice were given ivermectin orally every day for the remainder of the experiment at doses of 1 or 2 mg/kg after 24 h of LPS or BLM treatment. Ivermectin reversed severe lung injury caused by LPS or BLM challenge, including mortality, changes in diffuse ground-glass and consolidation shadows on lung CT imaging, lung histopathological scores, lung wet/dry ratio, and protein content in the bronchoalveolar lavage fluid (BALF). Furthermore, ivermectin also reduced total lung BALF inflammatory cells, infiltrating neutrophils, myeloperoxidase activity, and plasma TNF-α and IL-6 levels in mice treated with LPS or BLM. Finally, the mechanism study showed that LPS or BLM administration increased JNK, Erk1/2, and p38 MAPK phosphorylation while decreasing IκBα expression, an inhibitor of NF-κB. However, ivermectin increased IκBα expression but blocked elevated phosphorylated JNK and p38 MAPK, not Erk1/2, in both ALI mice. These findings suggested that ivermectin may alleviate ALI caused by LPS or BLM in mice, partly via lowering the inflammatory response, which is mediated at least by the inhibition of MAPK and NF-κB signaling. Collectively, ivermectin might be used to treat acute lung injury/acute respiratory distress syndrome.
Bronchoesophageal Fistula Requiring Venovenous ECMO After Minimally Invasive Esophagectomy
2020, Journal of Cardiothoracic and Vascular Anesthesia
The development of a tracheo- or broncho-esophageal fistula (TBF) is a rare but very serious complication of minimally invasive esophagectomy (MIE) with an incidence of 0.8-3.9% and mortality as high as 57%. We present the case of a 66-year-old male who underwent successful MIE for esophageal adenocarcinoma which was complicated by TBF and significant airway contamination. The patient was re-intubated with a double lumen endotracheal tube and placed emergently on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) due to severe acute respiratory distress syndrome (ARDS). This allowed for minimization of peak airway pressures applied to the repaired right mainstem bronchus while maintaining ventilation to the unaffected left lung. The patient rapidly improved following initiation of ECMO and was decannulated three days later; POD 15 from his original esophagectomy. He was extubated the next day and downgraded from the ICU three days later. To our knowledge, this is the first case description of ECMO as a rescue therapy for patients with TBF in the intensive care unit (ICU). The benefits of VV ECMO may derive from the facilitation of ultra-protective mechanical ventilation. Patient with ARDS are frequently ventilated with a protective ventilation strategy: tidal volume 4-8mL/kg ideal body weight and plateau pressures <30cmH₂O. However, VV ECMO allows patients to tolerate an ultra-protective ventilation strategy: tidal volume <4mL/kg ideal body weight and plateau pressures <25cmH₂O.(1) This important modality may become an increasingly common adjunct to treat such patients in the future.
Extracorporeal CO<inf>2</inf> Removal in Combination with Continuous Renal Replacement Therapy
2019, Archivos de Bronconeumologia

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REVISIÓNVentilación mecánica en pacientes tratados con membrana de oxigenación extracorpórea (ECMO)Mechanical ventilation in patients subjected to extracorporeal membrane oxygenation (ECMO)

Resumen

Abstract

Section snippets

Introducción

Lesión pulmonar inducida por ventilación mecánica

Modo de ventilación mecánica con membrana de oxigenación extracorpórea

Volumen tidal y presión meseta con membrana de oxigenación extracorpórea

Presión positiva al final de la espiración con membrana de oxigenación extracorpórea

Frecuencia respiratoria en ECMO

Fracción inspiratoria de O2 en pacientes con membrana de oxigenación extracorpórea

Conclusiones

Conflicto de intereses

Agradecimientos

Med Intensiva

Med Intensiva

Prone positioning in severe acute respiratory distress syndrome

N Engl J Med

Mortality rates for patients with acute lung injury/ARDS have decreased over time

Chest

Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: Systematic review and meta-analysis

Intensive Care Med

Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A (H1N1)

JAMA

Technological advances in extracorporeal membrane oxygenation for respiratory failure

Expert Rev Respir Med.

Contemporary extracorporeal membrane oxygenation for adult respiratory failure: Life support in the new era

Intensive Care Med

Tidal volume lower than 6 ml/kg enhances lung protection: Role of extracorporeal carbón dioxide removal

Anesthesiology

Lower tidal volume strategy (≈ 3 ml/kg) combined with extracorporeal CO2 removal versus conventional protective ventilation (6 ml/kg) in severe ARDS: The prospective randomized Xtravent-study

Intensive Care Med

Mechanical ventilation during extracorporeal membrane oxygenation. An international survey

Ann Am Thorac Soc

Towards ultraprotective mechanical ventilation

Curr Opin Anesthesiol

Mechanical ventilation during extracorporeal membrane oxygenation

Crit Care

Mechanical ventilation of acute respiratory distress síndromef

J Intensive Care Med

Lung regional metabolic activity and gas volume changes induced by tidal ventilation in patients with acute lung injury

Am J Respir Crit Care Med

Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome

N Engl J Med

Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: A retrospective international multicenter study

Crit Care Med

REVISIÓN
Ventilación mecánica en pacientes tratados con membrana de oxigenación extracorpórea (ECMO)Mechanical ventilation in patients subjected to extracorporeal membrane oxygenation (ECMO)

Lower tidal volume strategy (≈ 3 ml/kg) combined with extracorporeal CO₂ removal versus conventional protective ventilation (6 ml/kg) in severe ARDS: The prospective randomized Xtravent-study