ECMO as a Bridge to Lung Transplantation

See end of article for ECMO explained.
biomedme.com

“As waiting times for donor organs continue to increase, so does the need for bridging strategies for patients with end-stage lung disease awaiting transplantation,” said Doctor Marius M. Hoeper. “Our study shows that ECMO support in awake and non-intubated patients may be an alternative to intubation and mechanical ventilation, and may result in better survival.”

In the retrospective, single-centre study of consecutive lung transplantation candidates with terminal respiratory or cardiopulmonary failure, 26 patients received awake ECMO and 34 control patients received conventional mechanical ventilation (MV) as a bridge to transplant. Median duration of ECMO support was 9 days (range 1-45) and median duration of MV was 15 days (range 1-71). Veno-arterial ECMO was used primarily in patients with right ventricular failure and/or profound hypoxemia while the veno-venous approach was used primarily in patients exhibiting hypoxemic and/or hypercapnic respiratory failure but stable hemodynamics.

Of 26 patients in the ECMO group, six (23 per cent) died before a donor organ became available, compared with 10 of 34 (29 per cent) patients in the MV group. Among the patients who reached transplantation, the survival rate at six months post-transplantation was significantly (p=.02) higher in the awake ECMO group (80 per cent) compared with the MV group (50 per cent). The six-month survival rate among awake ECMO patients who required secondary intubation dropped to 43 per cent. Awake ECMO patents required significantly (p=.04) shorter postoperative mechanical ventilation and showed a trend towards shorter postoperative hospital stays.

ECMO-related complications included a fatal cardiac arrest after insertion of the venous ECMO cannulae in one patient. Intubation and mechanical ventilation was required 1-7 days after ECMO insertion in six patients. Blood transfusions due to bleeding complications were needed in eight patients. Of five patients who developed a sepsis-like syndrome, one recovered.

“Ours is the largest series of patients who underwent awake ECMO as a bridge to lung transplantation,” said Doctor Thomas Fuehner. “In addition to the possibility that this approach may improve survival, one of the main benefits of using awake ECMO is the avoidance of the complications associated with general anaesthesia, intubation, and long-term ventilation.”

The study had a few limitations, including the small number of patients included and the retrospective nature of the analyses. “Awake ECMO may be an effective bridging strategy for lung transplantation candidates,” said Hoeper. “This strategy, however, remains investigational and must be studied further to improve its safety and efficacy and examine how to tailor its use for specific patient populations.”
Source: American Thoracic Society

ECMO explained
In intensive care medicine, extracorporeal membrane oxygenation (ECMO) is an extracorporeal technique of providing both cardiac and respiratory support oxygen to patients whose heart and lungs are so severely diseased or damaged that they can no longer serve their function. Initial cannulation of a patient receiving ECMO is performed by a surgeon and maintenance of the patient is the responsibility of the ECMO Specialist and gives 24/7 monitoring care during the duration of the ECMO treatment.

An ECMO machine is similar to a heart-lung machine. To initiate ECMO, cannulae are placed in large blood vessels to provide access to the patient's blood. Anticoagulant drugs, usually heparin, are given to prevent blood clotting. The ECMO machine continuously pumps blood from the patient through a membrane oxygenator that imitates the gas exchange process of the lungs, i.e. it removes carbon dioxide and adds oxygen. Oxygenated blood is then returned to the patient.
Source: Wikipedia

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Portable artificial lung keeps patient alive for transplant

In addition to this article about bridge-to-transplant devices, also read my previous post about how surgeons at Toronto General Hospital (TGH) used the Novalung to save the life of a 16-year-old girl. The German-made machine is hooked up to both of the patient's legs. Blood is pumped from one leg and into a machine that removes the carbon dioxide, and re-oxygenates the blood, before it goes back into the body through the other leg. The machine essentially temporarily replaces the patient's lungs when they fail.

By R&Dmag.com

A 50-year-old former marathon runner with end-stage cystic fibrosis became one of the few in the world and the first in New York to use a new portable artificial lung to extend her life while waiting for a lung transplantation.

A standard respiratory ventilator was no longer effective at keeping the patient alive because her lungs had become too diseased.

Administered by the transplant team at NewYork-Presbyterian Hospital/Columbia University Medical Center, the device provided oxygen to the patient without her needing to rely on a ventilator. Bypassing her lungs, it oxygenated her blood directly through a two-way connection to a vein in her chest.

"The portable ECMO device, which works like an artificial lung, saved this woman's life," says Dr. Matthew Bacchetta, the thoracic surgeon at NewYork-Presbyterian Hospital/Columbia University Medical Center who led the transplant surgery. He is also assistant professor of surgery at Columbia University College of Physicians and Surgeons. "By connecting her to this machine, she was able to get the oxygen her body desperately needed. At the same time, she was able to eat, walk around, even talk on her own. As a result, she regained the strength needed to undergo a major surgery. This was a huge factor in making her transplant surgery a success."

The artificial lung is a state-of-the-art technology first developed in the early 1980s for neonatal care. Known as ECMO (extracorporeal membrane oxygenation), the machine oxygenates blood by pumping blood in and out of multiple tubes connected to a patient. A "membrane oxygenator" imitates the gas exchange process of the lungs, removing carbon dioxide and adding oxygen.

The artificial lung used for this patient at NewYork-Presbyterian/Columbia is constructed of components made by companies in the United States and Germany. A notable feature is a special cannula, or tube, that allows for a single connection, as opposed to the standard two connections, between the patient and the machine. This innovation makes it possible for patients to walk around with the portable oxygenator.

A standard respiratory ventilator requires patients to be sedated with a tube inserted in the mouth to oxygenate the patient's own lungs. In addition, patients on respirators are at risk for pneumonia, severe systemic infection, multi-organ failure and death.

"Just as left ventricular assist devices have saved the lives of countless patients with heart failure, we expect this machine may do the same for lung patients," Dr. Joshua R. Sonett, chief of general thoracic surgery and surgical director of the lung transplant program at NewYork-Presbyterian Hospital/Columbia University Medical Center and professor of clinical surgery at Columbia University College of Physicians and Surgeons. "And as the technology further develops, we might even see portable artificial lungs used as a longer-term treatment for some patients not eligible for transplantation."

Cystic Fibrosis
Cystic fibrosis is ranked as one of the most widespread life-shortening genetic diseases. The lung disease results from clogging of the airways due to mucosa build-up, which causes inflammation. Inflammation and infection cause injury and structural changes to the lungs, leading to a variety of medical problems. Respiratory failure is the most common cause of death.

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Has your life been saved by an organ transplant? "Pay it forward" and help spread the word about the need for organ donation - In the U.S. another person is added to the national transplant waiting list every 11 minutes and 18 people die each day waiting for an organ or tissue transplant.