Venovenous Extracorporeal Membrane Oxygenation in Awake Non-Intubated Patients With COVID-19 ARDS at High Risk for Barotrauma

Gianluca Paternoster, Pietro Bertini, Alessandro Belletti, Giovanni Landoni, Serena Gallotta, Diego Palumbo, Alessandro Isirdi, Fabio Guarracino, Gianluca Paternoster, Pietro Bertini, Alessandro Belletti, Giovanni Landoni, Serena Gallotta, Diego Palumbo, Alessandro Isirdi, Fabio Guarracino

Abstract

Objectives: To assess the efficacy of an awake venovenous extracorporeal membrane oxygenation (VV-ECMO) management strategy in preventing clinically relevant barotrauma in patients with coronavirus disease 2019 (COVID-19) with severe acute respiratory distress syndrome (ARDS) at high risk for pneumothorax (PNX)/pneumomediastinum (PMD), defined as the detection of the Macklin-like effect on chest computed tomography (CT) scan.

Design: A case series.

Setting: At the intensive care unit of a tertiary-care institution.

Participants: Seven patients with COVID-19-associated severe ARDS and Macklin-like radiologic sign on baseline chest CT.

Interventions: Primary VV-ECMO under spontaneous breathing instead of invasive mechanical ventilation (IMV). All patients received noninvasive ventilation or oxygen through a high-flow nasal cannula before and during ECMO support. The study authors collected data on cannulation strategy, clinical management, and outcome. Failure of awake VV-ECMO strategy was defined as the need for IMV due to worsening respiratory failure or delirium/agitation. The primary outcome was the development of PNX/PMD.

Measurements and main results: No patient developed PNX/PMD. The awake VV-ECMO strategy failed in 1 patient (14.3%). Severe complications were observed in 4 (57.1%) patients and were noted as the following: intracranial bleeding in 1 patient (14.3%), septic shock in 2 patients (28.6%), and secondary pulmonary infections in 3 patients (42.8%). Two patients died (28.6%), whereas 5 were successfully weaned off VV-ECMO and were discharged home.

Conclusions: VV-ECMO in awake and spontaneously breathing patients with severe COVID-19 ARDS may be a feasible and safe strategy to prevent the development of PNX/PMD in patients at high risk for this complication.

Keywords: COVID-19; Macklin effect; acute respiratory distress syndrome; barotrauma; extracorporeal membrane oxygenation; mechanical ventilation.

Conflict of interest statement

Conflict of Interest None.

Copyright © 2022 Elsevier Inc. All rights reserved.

Figures

Graphical abstract
Graphical abstract
Fig 1
Fig 1
Macklin-like radiologic sign on lung parenchyma window chest computed tomography scans (red arrows). (A) A crescent collection of air contiguous to the right main bronchus (coronal view) to the (B) left inferior lobar bronchovascular bundle, and (C) within the main right fissure.
Fig 2
Fig 2
Awake ECMO implantation algorithm. ECMO, extracorporeal membrane oxygenation. CT, computed tomography; EMCO,
Fig 3
Fig 3
Noninvasive ventilation strategies prior to ECMO implantation. ECMO, extracorporeal membrane oxygenation. ECMO, extracorporeal membrane oxygenation; HFNC, high-flow nasal cannula; PEEP, positive end expiratory pressure.

References

    1. Zangrillo A, Beretta L, Scandroglio AM, et al. Characteristics, treatment, outcomes and cause of death of invasively ventilated patients with COVID-19 ARDS in Milan, Italy. Crit Care Rescusc. 2020;22:200–211.
    1. Grasselli G, Zangrillo A, Zanella A, et al. Baseline Characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy. JAMA. 2020;323:1574–1581.
    1. Grasselli G, Greco M, Zanella A, et al. Risk factors associated with mortality among patients with COVID-19 in intensive care units in Lombardy, Italy. JAMA Intern Med. 2020;180:1345–1355.
    1. Belletti A, Palumbo D, Zangrillo A, et al. Predictors of pneumothorax/pneumomediastinum in mechanically ventilated COVID-19 patients. J Cardiothorac Vasc Anesth. 2021;35:3642–3651.
    1. McGuinness G, Zhan C, Rosenberg N, et al. Increased incidence of barotrauma in patients with COVID-19 on invasive mechanical ventilation. Radiology. 2020;297:E252–E262.
    1. Belletti A, Todaro G, Valsecchi G, et al. Barotrauma in coronavirus disease 2019 patients undergoing invasive mechanical ventilation: A systematic literature review. Crit Care Med. 2022;50:491–500.
    1. Lemmers DHL, Abu Hilal M, Bnà C, et al. Pneumomediastinum and subcutaneous emphysema in COVID-19: Barotrauma or lung frailty? ERJ Open Res. 2020;6:00385–02020.
    1. Martinelli AW, Ingle T, Newman J, et al. COVID-19 and pneumothorax: A multicentre retrospective case series. Eur Respir J. 2020;56
    1. Palumbo D, Campochiaro C, Belletti A, et al. Pneumothorax/pneumomediastinum in non-intubated COVID-19 patients: Differences between first and second Italian pandemic wave. Eur J Intern Med. 2021;88:144–146.
    1. Hamouri S, Samrah SM, Albawaih O, et al. Pulmonary barotrauma in COVID-19 Patients: Invasive versus noninvasive positive pressure ventilation. Int J Gen Med. 2021;14:2017–2032.
    1. Kahn MR, Watson RL, Thetford JT, et al. High incidence of barotrauma in patients with severe coronavirus disease 2019. J Intensive Care Med. 2021;36:646–654.
    1. Al-Azzawi M, Douedi S, Alshami A, et al. Spontaneous subcutaneous emphysema and pneumomediastinum in COVID-19 patients: An indicator of poor prognosis? Am J Case Rep. 2020;21
    1. Chopra A, Al-Tarbsheh AH, Shah NJ, et al. Pneumothorax in critically ill patients with COVID-19 infection: Incidence, clinical characteristics and outcomes in a case control multicenter study. Respir Med. 2021;184 2021.
    1. Murayama S, Gibo S. Spontaneous pneumomediastinum and Macklin effect: Overview and appearance on computed tomography. World J Radiol. 2014;6:850–854.
    1. Macklin CC. Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: Clinical implications. Arch Intern Med. 1939;64:913–926.
    1. Palumbo D, Zangrillo A, Belletti A, et al. A radiological predictor for pneumomediastinum/pneumothorax in COVID-19 ARDS patients. J Crit Care. 2021;66:14–19.
    1. Quintel M, Bartlett RH, Grocott MPW, et al. Extracorporeal membrane oxygenation for respiratory failure. Anesthesiology. 2020;132:1257–1276.
    1. Langer T, Santini A, Bottino N, et al. “Awake” extracorporeal membrane oxygenation (ECMO): Pathophysiology, technical considerations, and clinical pioneering. Crit Care. 2016;20:150.
    1. Schmidt M, Pineton de Chambrun M, Lebreton G, et al. Extracorporeal membrane oxygenation instead of invasive mechanical ventilation in a patient with severe COVID-19-associated acute respiratory distress syndrome. Am J Respir Crit Care Med. 2021;203:1571–1573.
    1. Azzam MH, Mufti HN, Bahaudden H, et al. Awake extracorporeal membrane oxygenation in coronavirus disease 2019 patients without invasive mechanical ventilation. Crit Care Explor. 2021;3:e0454.
    1. Li T, Yin P-F, Li A, et al. Acute respiratory distress syndrome treated with awake extracorporeal membrane oxygenation in a patient with COVID-19 pneumonia. J Cardiothorac Vasc Anesth. 2021;35:2467–2470.
    1. Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: The Berlin definition. JAMA. 2012;307:2526–2533.
    1. Alhazzani W, Møller MH, Arabi YM, et al. Surviving sepsis campaign: Guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19) Crit Care Med. 2020;48:e440–e469.
    1. Alhazzani W, Evans L, Alshamsi F, et al. Surviving sepsis campaign guidelines on the management of adults with coronavirus disease 2019 (COVID-19) in the ICU: First update. Crit Care Med. 2021;49:e219–e234.
    1. Foti G, Giannini A, Bottino N, et al. Management of critically ill patients with COVID-19: Suggestions and instructions from the coordination of intensive care units of Lombardy. Minerva Anestesiol. 2020;86:1234–1245.
    1. Shekar K, Badulak J, Peek G, et al. Extracorporeal life support organization coronavirus disease 2019 interim guidelines: A consensus document from an international group of interdisciplinary extracorporeal membrane oxygenation providers. ASAIO J. 2020;66:707–721.
    1. Paternoster G, Sartini C, Pennacchio E, et al. Awake pronation with helmet continuous positive airway pressure for COVID-19 acute respiratory distress syndrome patients outside the ICU: A case series. Med Intensiva (Engl Ed) 2020;46:65–71.
    1. Sartini C, Tresoldi M, Scarpellini P, et al. Respiratory parameters in patients with COVID-19 after using noninvasive ventilation in the prone position outside the intensive care unit. JAMA. 2020;323:2338–2340.
    1. Pisano A, Yavorovskiy A, Verniero L, et al. The impact of anesthetic regiment on outcomes in adult cardiac surgery: A narrative review. J Cardiothorac Vasc Anesth. 2021;35:711–729.
    1. Bazan VM, Taylor EM, Gunn TM, et al. Overview of the bicaval dual lumen cannula. Indian J Thorac Cardiovasc Surg. 2021;37:232–240.
    1. Colman E, Yin EB, Laine G, et al. Evaluation of a heparin monitoring protocol for extracorporeal membrane oxygenation and review of the literature. J Thorac Dis. 2019;11:3325–3335.
    1. Hoeper MM, Wiesner O, Hadem J, et al. Extracorporeal membrane oxygenation instead of invasive mechanical ventilation in patients with acute respiratory distress syndrome. Intensive Care Med. 2013;39:2056–2057.
    1. Montero S, Huang F, Rivas-Lasarte M, et al. Awake venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock. Eur Heart J Acute Cardiovasc Care. 2021;10:585–594.
    1. Hoopes CW, Kukreja J, Golden J, et al. Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation. J Cardiothorac Vasc Anesth. 2013;145:862–868.
    1. Stahl K, Schenk H, Kühn C, et al. Extracorporeal membrane oxygenation in non-intubated immunocompromised patients. Crit Care. 2021;25:164.
    1. Crotti S, Bottino N, Ruggeri GM, et al. Spontaneous breathing during extracorporeal membrane oxygenation in acute respiratory failure. Anesthesiology. 2017;126:678–687.
    1. Assanangkornchai N, Slobod D, Qutob R, et al. Awake venovenous extracorporeal membrane oxygenation for coronavirus disease 2019 acute respiratory failure. Crit Care Explor. 2021;3:e0489.
    1. Loyalka P, Cheema FH, Rao H, et al. Early usage of extracorporeal membrane oxygenation in the absence of invasive mechanical ventilation to treat COVID-19-related hypoxemic respiratory failure. ASAIO J. 2021;67:392–394.
    1. Barbaro RP, MacLaren G, Boonstra PS, et al. Extracorporeal membrane oxygenation support in COVID-19: An international cohort study of the Extracorporeal Life Support Organization registry. Lancet. 2020;396:1071–1078.
    1. Lorusso R, Combes A, Coco VL, et al. ECMO for COVID-19 patients in Europe and Israel. Intensive Care Med. 2021;47:344–348.
    1. Belletti A, Landoni G, Zangrillo A. Pneumothorax and barotrauma in invasively ventilated patients with COVID-19. Respir Med. 2021;187
    1. Wilkerson RG, Adler JD, Shah NG, et al. Silent hypoxia: A harbinger of clinical deterioration in patients with COVID-19. Am J Emerg Med. 2020;38:2243.e5–2243.e6.
    1. Battaglini D, Robba C, Ball L, et al. Noninvasive respiratory support and patient self-inflicted lung injury in COVID-19: A narrative review. Br J Anaesth. 2021;127:353–364.
    1. Spinelli E, Mauri T, Beitler JR, et al. Respiratory drive in the acute respiratory distress syndrome: Pathophysiology, monitoring, and therapeutic interventions. Intensive Care Med. 2020;46:606–618.
    1. Zangrillo A, Landoni G, Biondi-Zoccai G, et al. A meta-analysis of complications and mortality of extracorporeal membrane oxygenation. Crit Care Resusc. 2013;15:172–178.
    1. Combes A, Hajage D, Capellier G, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med. 2018;378:1965–1975.
    1. Fan E, Del Sorbo L, Goligher EC, et al. An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2017;195:1253–1263.
    1. National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. Moss M, Huang DT, et al. Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med. 2019;380:1997–2008.
    1. Griffiths MJD, McAuley DF, Perkins GD, et al. Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res. 2019;6
    1. Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators. Cavalcanti AB, Suzumura ÉA, et al. Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome: A randomized clinical trial. JAMA. 2017;318:1335–1345.
    1. Combes A, Peek GJ, Hajage D, et al. ECMO for severe ARDS: Systematic review and individual patient data meta-analysis. Intensive Care Med. 2020;46:2048–2057.
    1. Brochard L, Slutsky A, Pesenti A. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Am J Respir Crit Care Med. 2017;195:438–442.
    1. Bellani G, Grasselli G, Teggia-Droghi M, et al. Do spontaneous and mechanical breathing have similar effects on average transpulmonary and alveolar pressure? A clinical crossover study. Crit Care. 2016;20:142.
    1. Brochard L. Ventilation-induced lung injury exists in spontaneously breathing patients with acute respiratory failure: Yes. Intensive Care Med. 2017;43:250–252.
    1. Carteaux G, Parfait M, Combet M, et al. Patient-self inflicted lung injury: A practical review. J Clin Med. 2021;10:2738.

Source: PubMed

赞助者和合作者

医疗条件

药物干预

3
订阅