Critical Care Medicine  |   April 2017
Spontaneous Breathing during Extracorporeal Membrane Oxygenation in Acute Respiratory Failure
Author Notes
  • From the Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy (S.C., N.B., E.S., D.T., A.L., A.P.); and Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, and Università degli Studi di Milano, Milan, Italy (G.M.R.); and Department of Anesthesia and Intensive Care, Georg-August-Universität, Göttingen, Germany (L.G.). The work was performed at the Intensive Care Unit “E.Vecla,” Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy.
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    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication July 29, 2016. Accepted for publication January 6, 2017.
    Submitted for publication July 29, 2016. Accepted for publication January 6, 2017.×
  • Address correspondence to Dr. Crotti: Department of Anesthesia and Intensive Care, Intensive Care Unit “E.Vecla,” Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan 20121, Italy. stefania.crotti@policlinico.mi.it. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Critical Care Medicine / Clinical Science / Critical Care / Respiratory System / Thoracic Anesthesia
Critical Care Medicine   |   April 2017
Spontaneous Breathing during Extracorporeal Membrane Oxygenation in Acute Respiratory Failure
Anesthesiology 4 2017, Vol.126, 678-687. doi:10.1097/ALN.0000000000001546
Anesthesiology 4 2017, Vol.126, 678-687. doi:10.1097/ALN.0000000000001546
Abstract

Background: We evaluate the clinical feasibility of spontaneous breathing on extracorporeal membrane oxygenation and the interactions between artificial and native lungs in patients bridged to lung transplant or with acute exacerbation of chronic obstructive pulmonary disease (COPD) or acute respiratory distress syndrome.

Methods: The clinical course of a total of 48 patients was analyzed. Twenty-three of 48 patients were enrolled in the prospective study (nine bridged to lung transplant, six COPD, and eight acute respiratory distress syndrome). The response to the carbon dioxide removal was evaluated in terms of respiratory rate and esophageal pressure swings by increasing (“relief” threshold) and decreasing (“distress” threshold) the extracorporeal membrane oxygenation gas flow, starting from baseline condition.

Results: Considering all 48 patients, spontaneous breathing extracorporeal membrane oxygenation was performed in 100% bridge to lung transplant (9 of 9 extubated), 86% COPD (5 of 6 extubated), but 27% acute respiratory distress syndrome patients (6 of 8 extubated; P < 0.001) and was maintained for 92, 69, and 38% of the extracorporeal membrane oxygenation days (P = 0.021), respectively. In all the 23 patients enrolled in the study, gas flow increase (from 2.3 ± 2.2 to 9.2 ± 3.2 l/min) determined a decrease of both respiratory rate (from 29 ± 6 to 8 ± 9 breaths/min) and esophageal pressure swings (from 20 ± 9 to 4 ± 4 cm H2O; P < 0.001 for all). All COPD and bridge to lung transplant patients were responders (reached the relief threshold), while 50% of acute respiratory distress syndrome patients were nonresponders.

Conclusions: Carbon dioxide removal through extracorporeal membrane oxygenation relieves work of breathing and permits extubation in many patients, mainly bridge to lung transplant and COPD. Only few patients with acute respiratory distress syndrome were able to perform the spontaneous breathing trial, and in about 50% of these, removal of large amount of patient’s carbon dioxide production was not sufficient to prevent potentially harmful spontaneous respiratory effort.