Use of Single-Cannula Venous-Venous Extracorporeal Life Support in the Management of Life-Threatening Airway Obstruction

Extracorporeal membrane oxygenation in critical airway interventional therapy: A review

Introduction

Extracorporeal membrane oxygenation (ECMO) is widely used during refractory cardiac or respiratory failure, and some case reports described ECMO utilization in critical airway interventional therapy.

Methods

Eligible reports about patients receiving airway interventional therapy under ECMO were retrieved from Web of Science, Embase, Medline, and Cochrane databases up to 1 August 2022.

Results

Forty-eight publications including 107 patients who underwent ECMO for critical airway problems met the inclusion criteria. The critical airway problem that was reported the most was tumor-associated airway obstruction (n = 66, 61.7%). The second most reported etiology was postoperative airway collapse or stenosis (n = 19, 17.8%). The main interventional therapies applied were airway stent placement or removal (n = 61, 57.0%), mass removal (n = 22, 20.6%), and endotracheal intubation (n = 12, 11.2%) by bronchoscopy. The median ECMO duration was 39.5 hours. Eleven patients had ECMO-associated complications, including seven cases of airway hemorrhage, one case of arteriovenous fistula, one case of vein rupture and hematoma, one case of foot ischemia, and one case of neuropraxia of the cannulation site. In total, 91.6% of the patients survived and were discharged from the hospital.

Conclusion

ECMO appears to be a viable form of life support for patients undergoing interventional therapy for critical airway problems.

Multivariate Analysis of Risk Factor for Mortality and Feasibility of Extracorporeal Membrane Oxygenation in High-Risk Thoracic Surgery

Background: Extracorporeal membrane oxygenation (ECMO) as intraoperative cardiorespiratory support during lung transplantation is well known, but use for other types of surgery are limited. To assess risk factor for mortality after high-risk thoracic surgery and feasibility of ECMO, we reviewed.

Methods: This study was an observational study. Between January 2011 and October 2018, 63 patients underwent thoracic surgery with ECMO for severe airway disease, pulmonary insufficiency requiring lung surgery, and other conditions.

Results: In all, 46 patients remained alive at 30 days after surgery. The mean patient age was 50.38 ± 16.16 years. ECMO was most commonly used to prevent a lethal event (34 [73.9%]) in the Survival (S) group and rescue intervention (13 [76.5%]) in the Non-survival (N) group. In all, 11 patients experienced arrest during surgery (S vs N: 2 [4.3%] vs 9 [52.9%], p ≤0.001). The multivariate analysis revealed that arrest during surgery (odds ratio [OR], 24.44; 95% confidence interval [CI], 1.82–327.60; p = 0.016) and age (OR, 7.47; 95% CI, 1.17–47.85; p = 0.034) were independently associated with mortality.

Conclusions: ECMO provides a safe environment during thoracic surgery, and its complication rate is acceptable except for extracorporeal cardiopulmonary resuscitation (ECPR).

[Extracorporeal Lung Support in Thoracic Surgery: Basics and Pathophysiology]

Extracorporeal lung support (ECLS) is of increasing importance in general thoracic surgery. Different modes of ECLS may be applied in several situations throughout the perioperative phase and are adapted to the individual patient's needs and the planned surgical procedures. ECLS is not a static procedure and should be always evaluated according to the present condition of the patient. Therefore, it is essential to understand the pathophysiology of the disease and the different ECLS modes, as well as the different cannulation options, in order to be able to use the different escalation and de-escalation techniques in accordance with the clinical situation.

Pre-Intubation Veno-Venous Extracorporeal Membrane Oxygenation in Patients at Risk for Respiratory Decompensation

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has emerged as a potential life-saving treatment for patients with acute respiratory failure. Given the accumulating literature supporting the use of VV-ECMO without therapeutic levels of anticoagulation, it might be feasible to use it for planned intubation before surgical procedures. Here, we report consecutive series of patients who underwent planned initiation of VV-ECMO, without anticoagulation, before induction of general anesthesia for anticipated difficult airways or respiratory decompensation. We describe the approach to safely initiate VV-ECMO in an awake patient. We retrospectively identified patients in a prospectively maintained database who underwent planned initiation of VV-ECMO before intubation. Standard statistical methods were used to determine post-procedure outcomes. Patients included were three men and one woman, with a mean age of 34.3 ± 10.4 years. Indications included mediastinal lymphoma, foreign body obstruction, hemoptysis, and tracheo-esophageal fistula. VV-ECMO was initiated electively for all patients, and no anticoagulation was used. The median duration of VV-ECMO support was 2.5 days (1-11 days), the median length of ventilator dependence and intensive care unit stay was 1 day (1-23 days) and 5 days (4-31 days), respectively. The median length of stay was 18.5 days (8-39 days). There were no thrombotic complications and no mortality at 30 days. Initiation of awake VV-ECMO is feasible and is safe before intubation and induction of anesthesia in patients at high risk for respiratory decompensation.

Extracorporeal Membrane Oxygenation During Adult Noncardiac Surgery and Perioperative Emergencies: A Narrative Review

Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has increased significantly. In some centers, ECMO has been deployed to manage perioperative emergencies and plays a role in facilitating high-risk thoracic, airway, and trauma surgery, which may not be feasible without ECMO support. General anesthesiologists who usually manage these cases may not be familiar with the initiation and management of patients on ECMO. This review discusses the use of ECMO in the operating room for thoracic, airway, and trauma surgery, as well as obstetric and perioperative emergencies.

The peripheral cannulas in extracorporeal life support

Femoral cannulation is a minimally invasive method which is an alternative method for central cannulation. This review focuses on the parameters and features of the available peripheral cannulas. Nowadays there exist many peripheral cannulas in a variety of sizes, configurations and lengths to meet the specific needs of the patients. Modern cannulas are strong, thin-walled and one piece reinforced constructions. Furthermore, modern cannulas are manufactured from a biocompatible material and surface coatings are applied to the cannulas to reduce the activation of the clotting. When peripheral cannulas are applied, bleeding, thrombosis and hemolysis are the most common complications.

Extended Indications for Extracorporeal Membrane Oxygenation in the Operating Room

Background:

The use of extracorporeal life support (ECLS) for cardiorespiratory support is increasing. Traditional absolute contraindications are currently deemed relative contraindications. Extracorporeal life support is now considered for a wider cohort of patients on a case-by-case basis.

Method:

We performed a review of the literature and examined current Extracorporeal Life Support Organization guidelines that support the use of ECLS in the operating room, based on the underlying pathology and surgical procedure proposed. We discuss specific surgical populations and different modes of ECLS and cannulation strategies.

Results:

Based on the available literature, veno-venous extracorporeal membrane oxygenation (ECMO) can be used for the management of complex tracheobronchial and lung surgery, both in the elective and in the emergent setting. Elective veno-arterial (V-A) ECMO for cardiocirculatory support should be considered in high-risk patients undergoing ventricular tachycardia ablation. Extracorporeal life support should be considered as a potential life-saving intervention in almost all parturients with severe respiratory failure or refractory cardiogenic shock. V-A ECMO should be considered in unanticipated intraoperative cardiac arrest in patients without preexisting end-organ failure.

Conclusion:

As the number of indications for ECLS in the operating room is growing, anesthesiology and surgical staff should become familiar with the perioperative management of patients on ECLS.

Principles and indications of extracorporeal life support in general thoracic surgery

The role of extracorporeal life support (ECLS) has expanded rapidly over the past 15 years to become an important tool in advanced general thoracic surgery practice. Intra-operative and in some cases continued post-operative ECLS is redefining the scope of complex surgical care. ECLS encompasses a spectrum of temporary mechanical support that may remove CO₂, oxygenate or provide hemodynamic support or a combination thereof. The most common modalities used in general thoracic surgery include extracorporeal membrane oxygenation (ECMO), interventional lung assist device (iLA^® Novalung^®, Heilbronn, Germany), and extracorporeal CO₂ removal (ECCO₂R). The ECMO and Novalung^® devices can be used in different modes for the short term or long-term support depending on the situation. In this review, the principles and current applications of ECLS in general thoracic surgery are presented.

Respiratory support with venovenous extracorporeal membrane oxygenation during stent placement for the palliation of critical airway obstruction: case series analysis

BACKGROUND

Venovenous extracorporeal membrane oxygenation (VV ECMO) is used to support gas transfer of patients suffering from respiratory failure during various procedures. The purpose of this study was to evaluate the technical feasibility and safety of fluoroscopic stent placement under respiratory support with VV ECMO in patients with critical airway obstructions.

METHODS

We reviewed the records of 17 patients (14 male and 3 female; mean age: 63 years; range, 30-82 years) who underwent self-expandable metallic stent (SEMS) placement under VV ECMO respiratory support for critical airway obstruction caused by malignant (n=16) or benign (n=1) etiology.

RESULTS

Fluoroscopic placement of SEMS was successful in all patients (100%) with no procedure-related complications. During a mean follow-up of 83 days (range, 10-367 days), 15 (88.2%) of 17 patients showed improvement of Hugh-Jones grades (from 4.7±0.4 to 3.1±0.9, P<0.001). Removal of the endotracheal tube was possible in 11 (84.6%) of 13 patients. Weaning off ECMO was successful in all patients. The ECMO-related and stent-related complication rates were 11.7% (n=2) and 29.4% (n=5), respectively, all successfully managed by additional interventions. Indications for VV ECMO included failure of mechanical ventilation in 13 (76.5%) patients, and orthopnea in 4 (23.5%) patients.

CONCLUSIONS

Fluoroscopic stent placement under VV ECMO respiratory support can be successfully performed in patients with critical airway obstruction, especially in cases of respiratory distress despite ventilation support and an inability to lie in a supine position. However, further studies will be needed to validate the standardized methods and specific indications.

Extracorporeal support in airway surgery

Extracorporeal life support (ECLS) is increasingly used for major airway surgery. It facilitates complex reconstructions and maintains gas exchange during endoscopic procedures in patients with critical airway obstruction. ECLS offers the advantage of an uncluttered surgical field and eliminates the need for crossing ventilation tubes, thus, making precise surgical dissection easier. ECLS is currently used for hemodynamic and respiratory support in lung transplantation as well as extended tumor resections with an acceptable risk profile. This work reviews the published experience of ECLS in airway surgery both in adults and in pediatric patients. It highlights currently available devices and their indications.

Cardiopulmonary Bypass and Extracorporeal Life Support for Emergent Intraoperative Thoracic Situations

Intraoperative thoracic surgical catastrophes may require extracorporeal circulation modes to support the patient while the appropriate repair is made. Teamwork is key and, given the evidence supporting better performance with the use of simulation and surgical-crisis checklists, their use should be encouraged. Anticipation is another important factor because the results of intrathoracic malignancy resection are clearly superior in the setting of planned cardiopulmonary support. In addition, familiarity with the different modes of support that are currently available can direct the decision-making process toward the best option to facilitate resolution of the intraoperative catastrophe with the least related morbidity.

Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: history, current applications, and future directions

Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal life support that augments oxygenation, ventilation and/or cardiac output via cannulae connected to a circuit that pumps blood through an oxygenator and back into the patient. ECMO has been used for decades to support cardiopulmonary disease refractory to conventional therapy. While not robust, there are promising data for the use of ECMO in acute hypoxemic respiratory failure, cardiac arrest, and cardiogenic shock and the potential indications for ECMO continue to increase. This review discusses the existing literature on the potential use of ECMO in critically ill patients within the emergency department.

Intraoperative veno-venous extracorporeal lung support in thoracic surgery: a single-centre experience

OBJECTIVES

Intraoperative extracorporeal lung support (ECLS) during thoracic surgical procedures is a modern concept that is gaining increasing acceptance. So far, cardiopulmonary bypass (CPB), veno-arterial extracorporeal membrane oxygenation (v-a-ECMO) or pumpless arterio-venous interventional lung assist (iLA) were utilized for intraoperative support. Only a few case reports have described the use of veno-venous ECMO for intraoperative ECLS. Here, we report our experience with intraoperative ECLS using different veno-venous low-flow and high-flow settings adapted to the individual patient requirements.

METHODS

Between April 2014 and April 2015, 9 patients underwent pulmonary resections under ECLS. In 6 patients, a twin-port double-lumen cannula was inserted percutaneously into the right femoral vein for low-flow ECLS. In 3 patients, high-flow ECLS was achieved either by femoro-atrial (n = 1) or femoro-jugular cannulation.

RESULTS

Indications for ECLS were severely impaired lung function (n = 3), previous pulmonary resections including contralateral pneumonectomy (n = 4), previous single-lung transplantation (sLTX) (n = 1) and extended carinal pneumonectomy (n = 1). Procedures included segmentectomy (n = 3), extended lobectomy with bronchial and vascular anastomoses (n = 1), VATS lobectomy (n = 2), extended left-sided carinal pneumonectomy (n = 1) as well as extended metastasectomy (n = 2). Low-flow ECLS allowed for apnoea up to 45 min in patients with previous pneumonectomy (n = 3) and facilitated protective single-lung ventilation in patients (n = 3) with severely impaired pulmonary function. During trans-sternal carinal pneumonectomy (n = 1), high-flow ECLS achieved by femoro-atrial cannulation allowed for apnoea for 40 min, avoiding cross-field ventilation. In 2 patients requiring extended metastasectomy after previous lobectomy of the contralateral lower lobe (n = 1) or pulmonary metastases in the graft after sLTX for end-stage fibrosis (n = 1), high-flow ECLS by percutaneous femoro-jugular cannulation allowed for extensive metastasectomy under optimal atelectasis of the lung.

CONCLUSIONS

For intraoperative ECLS, different modes may be applied depending on the intended procedures and required mechanical ventilation. In our experience, different settings of veno-venous ECLS provide sufficient partial or complete lung support, avoiding possible complications associated with other forms of extracorporeal support such as CPB or v-a-ECMO.