Long-Term Outcomes After Extracorporeal Life Support for Acute Respiratory Failure

Long-term outcomes of patients supported with extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome (ARDS). The impact of ECMO on long-term outcomes of patients with severe ARDS is unclear.

METHODS

We searched electronic databases from inception to January 17th 2023. We selected clinical trials and observational studies reporting on long-term outcomes of patients supported with ECMO for ARDS. Health-related quality of life (HRQoL) was the primary outcome. Secondary outcomes included cognitive function, mental health, functional status, respiratory symptoms, and return to work.

RESULTS

Of the 7126 screened citations, 1 randomized clinical trial and 31 observational studies were included, of which 7 compared conventional mechanical ventilation (CMV) and ECMO. Overall quality of studies of the included studies was limited, with the majority being either low (45%) or fair (32%) quality. There was no significant difference in HRQoL measured with the SF-36 score between ECMO and CMV patients (physical component score [PCS]: mean difference 3.91 (- 6.22 to 14.05), mental component score [MCS] mean difference 1.33 (- 3.93 to 6.60)). There was no difference between cognitive function, mental health, functional status, and respiratory symptoms between ECMO and CMV, but data available for comparison were limited. There were high rates of disability for ECMO survivors with 49% of patients returning to work and 23% needing assistance at home on follow-up.

CONCLUSION

Survivors of ECMO for ARDS experience significant disability in multiple domains. Further studies are needed to examine the effect of ECMO on long-term outcomes of patients compared to CMV.

Quality of life after extra corporeal life support therapy

BACKGROUND

Extra Corporeal Life Support (ECLS) may be a life-saving treatment for patients with reversible cardiac and/or respiratory failure. ECLS is associated with a high risk of complications and mortality. Because only a small number of studies have been conducted into the long-term effects of ECLS, we investigated the difference in quality of life, anxiety and depressive complaints and PTSD 3 months after ICU discharge.

METHOD

It is a retrospective case-control study covering the period January 2012 to December 2017. The ECLS patient group was compared to a matched similar patient group in the Intensive Care (IC) that did not have ECLS therapy. Quality of life was measured with the Short-Form-36 (SF-36) questionnaire, anxiety and depression was measured with the Hospital Anxiety and Depression Scale (HADS) questionnaire and for PTSD the Impact of Events Scale (IES) questionnaire was used, comparing sum scores and cut-off points of scores from both groups.

RESULTS

Included were 19 patients in the ECLS group and 38 in the control group. The mean sum scores on the sub scales of the SF36 questionnaire were the same for both groups. Only the mean score of 66.2 (scale 0-100) on the domain 'general health experience' was statistically significantly different in the ECLS group than in the control group (56.8, p = .02). There was no significant difference between the sum scores of both groups on anxiety and depressive complaints. In the ECLS group 32% of the patients may have a depressive disorder versus 18% from the control group (p = .32). And 26% of the patients from the ECLS group may have an anxiety disorder versus 7% from the control group (p = .51). The incidence of PTSD was 42% in the ECLS group and 24% in the control group (p = .22).

CONCLUSION

We found no statistically significant difference in quality of life, anxiety and depressive symptoms and PTSD symptoms between ECLS patients and the matched control group - 3 months after the ICU discharge. The incidence of anxiety and depressive symptoms and PTSD in the ECLS group is higher than in the control group, however, this difference is not significant.

Long-Term Outcomes of Extracorporeal Life Support in Respiratory Failure

Although extracorporeal life support is an expensive method with serious risks of complications, it is nowadays a well-established and generally accepted method of organ support. In patients with severe respiratory failure, when conventional mechanical ventilation cannot ensure adequate blood gas exchange, veno-venous extracorporeal membrane oxygenation (ECMO) is the method of choice. An improvement in oxygenation or normalization of acid-base balance by itself does not necessarily mean an improvement in the outcome but allows us to prevent potential negative effects of mechanical ventilation, which can be considered a crucial part of complex care leading potentially to an improvement in the outcome. The disconnection from ECMO or discharge from the intensive care unit should not be viewed as the main goal, and the long-term outcome of the ECMO-surviving patients should also be considered. Approximately three-quarters of patients survive the veno-venous ECMO, but various (both physical and psychological) health problems may persist. Despite these, a large proportion of these patients are eventually able to return to everyday life with relatively little limitation of respiratory function. In this review, we summarize the available knowledge on long-term mortality and quality of life of ECMO patients with respiratory failure.

The lived experience by patients and family members of extracorporeal membrane oxygenation: A qualitative study

OBJECTIVE

To examine the lived experience of extracorporeal membrane oxygenation (ECMO) by patients and their families, and their relationship with intensive care clinicians.

RESEARCH METHODOLOGY

Semi-structured interviews were conducted with six patients who had received ECMO and with four of their family members. The data were analysed narratively using a constant comparative method.

SETTING

Patients were treated at a major acute care hospital in British Columbia between 2014 and 2021. ECMO was used either as a bridge to recovery or to organ transplant. Four had family members bedside throughout, while two had virtual visits due to COVID-19 infection control measures.

FINDINGS

ECMO was experienced through a triad of relationships between the patient, key family members and key clinicians. The strength, directionality and focus of these relationships shifted during therapy and realigned once ECMO was removed. The largest shift involved family members. Post-ECMO, patients relied almost entirely on spouses, adult children and clinical team members to reconstruct their experience. The connection between families and clinical team members was limited and changed little.

CONCLUSIONS

The lived experience of ECMO was complex in ways yet to be comprehensively reported in the literature. This technology had particular impact on family members when ECMO was used as a bridge to transplant and where run times extended to multiple weeks. COVID-19 infection control restrictions further complicated how this technology was experienced. Findings from this study highlight the importance of intensive care nurses recognising the critical role family members play as witnesses whose experiences later allow patients to make sense of their journey post-discharge.

The association of the Activities of Daily Living and the outcome of old intensive care patients suffering from COVID-19

Purpose

Critically ill old intensive care unit (ICU) patients suffering from Sars-CoV-2 disease (COVID-19) are at increased risk for adverse outcomes. This post hoc analysis investigates the association of the Activities of Daily Living (ADL) with the outcome in this vulnerable patient group.

Methods

The COVIP study is a prospective international observational study that recruited ICU patients ≥ 70 years admitted with COVID-19 (NCT04321265). Several parameters including ADL (ADL; 0 = disability, 6 = no disability), Clinical Frailty Scale (CFS), SOFA score, intensive care treatment, ICU- and 3-month survival were recorded. A mixed-effects Weibull proportional hazard regression analyses for 3-month mortality adjusted for multiple confounders.

Results

This pre-specified analysis included 2359 patients with a documented ADL and CFS. Most patients evidenced independence in their daily living before hospital admission (80% with ADL = 6). Patients with no frailty and no disability showed the lowest, patients with frailty (CFS ≥ 5) and disability (ADL < 6) the highest 3-month mortality (52 vs. 78%, p < 0.001). ADL was independently associated with 3-month mortality (ADL as a continuous variable: aHR 0.88 (95% CI 0.82–0.94, p < 0.001). Being “disable” resulted in a significant increased risk for 3-month mortality (aHR 1.53 (95% CI 1.19–1.97, p 0.001) even after adjustment for multiple confounders.

Conclusion

Baseline Activities of Daily Living (ADL) on admission provides additional information for outcome prediction, although most critically ill old intensive care patients suffering from COVID-19 had no restriction in their ADL prior to ICU admission. Combining frailty and disability identifies a subgroup with particularly high mortality.

Trial registration number: NCT04321265.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-00996-9.

Can Cardiopulmonary Rehabilitation Facilitate Weaning of Extracorporeal Membrane Oxygenation (CaRe-ECMO)? Study Protocol for a Prospective Multidisciplinary Randomized Controlled Trial

Background: Mortality of patients suffering from critical illness has been dramatically improved with advanced technological development of extracorporeal membrane oxygenation (ECMO) therapy. However, the majority of ECMO-supported patients failed to wean from ECMO therapy. As one of several options, cardiopulmonary rehabilitation serves as effective intervention in the improvement of cardiovascular and respiratory function in various major critical illness. Nonetheless, its role in facilitating ECMO weaning has not yet been explored. The purpose of this study is to investigate the effectiveness of cardiopulmonary rehabilitation on rate of ready for ECMO weaning in ECMO-supported patients (CaRe-ECMO).

Methods: The CaRe-ECMO trial is a randomized controlled, parallel group, clinical trial. This trial will be performed in a minimum number of 366 ECMO-supported eligible patients. Patients will be randomly assigned to either: (1) the CaRe-ECMO group, which will be treated with usual care including pharmacotherapy, non-pharmacotherapy, and specific nursing for ECMO therapy and the CaRe-ECMO program; or (2) the control group, which will receive usual care only. The CaRe-ECMO program consists of protocolized positioning, passive range of motion (PROM) training, neuromuscular electrical stimulation (NMES), surface electrical phrenic nerve stimulation (SEPNS), and pulmonary rehabilitation. The primary outcome of the CaRe-ECMO trial is the rate of ready for ECMO weaning at CaRe-ECMO day 7 (refers to 7 days after the CaRe-ECMO program initiation). Secondary outcomes include rate of ECMO and mechanical ventilation weaning, total length in day of ready for ECMO weaning, ECMO weaning and mechanical ventilation, all-cause mortality, rate of major post-ECMO complications, ECMO unit length of stay (LOS) and hospital LOS, total cost for hospitalization, cerebral performance category (CPC), activities of daily living (ADL), and health-related quality of life (HRQoL).

Discussion: The CaRe-ECMO is designed to answer the question “whether cardiopulmonary rehabilitation can facilitate weaning of ECMO (CaRe-ECMO).” Should the implementation of the CaRe-ECMO program result in superior primary and secondary outcomes as compared to the controls, specifically the add-on effects of cardiopulmonary rehabilitation to the routine ECMO practice for facilitating successful weaning, the CaRe-ECMO trial will offer an innovative treatment option for ECMO-supported patients and meaningfully impact on the standard care in ECMO therapy.

Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT05035797.

Health-related outcomes of extracorporeal membrane oxygenation in adults: A cross-sectional study

BACKGROUND

Patients with critical illness may face challenges after hospital discharge; therapeutic outcomes of extracorporeal membrane oxygenation (ECMO) are typically measured by survival rate. However, ECMO is an integral part of treatment in critical care medicine, which requires an outcome measure beyond survival. Post-discharge health-related quality of life (HRQoL) is such an indicator.

OBJECTIVES

To measure HRQoL in adult patients who had previously undergone ECMO and explore influential factors related to HRQoL.

METHODS

This cross-sectional descriptive study used a convenience sample of patients discharged between April 2006-April 2016 after at least one month following ECMO. The study was conducted from October 2015 to October 2016, which included data collected from structured questionnaires: the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised and Short-Form Survey-36-v2. Stepwise linear regression determined predictor variables of physical and mental HRQoL.

RESULTS

Age of participants (N = 144) ranged from 24 to 81 years; long-term survival rate was 28.6% after a median follow-up of 1060 days (range = 44-3150 days). Mean scores for physical and mental components of HRQoL were 46.32 and 50.39, respectively. Level of HRQoL was low to moderate. Employment affected all physical components of HRQoL; depression was the main predictor for physical and mental components. Self-perceived health status and anxiety were also factors that influenced HRQoL.

CONCLUSIONS

Variables of employment, self-perceived health status and mental health influenced HRQoL. Early assessment of these factors by healthcare professionals can allow integration of multidimensional interventions following hospital discharge, which could improve HRQoL for patients weaned from ECMO.

Quality of life and functional status of patients treated with venovenous extracorporeal membrane oxygenation at 6 months

PURPOSE

Quality of life (QoL) outcomes of patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) have been conflicting. This study reports on QoL outcomes for a broad group of ARDS patients managed with up-to-date treatment modalities.

METHODS

We prospectively recruited patients at a quaternary hospital in the United Kingdom from 2013 to 2015 who were treated with ECMO for ARDS. We evaluated their pulmonary function and QoL at 6-months after admission using three QoL instruments: EuroQoL 5D (EQ-5), HADS, and PTSS-14.

RESULTS

Forty-three patients included in the analysis had near-normal pulmonary function at 6 months. HADS showed moderate-to-severe anxiety and depression in 32% and 11% of patients, respectively. PTSS-14 showed 29% had signs of post-traumatic stress disorder. EQ-5D showed that 67% of patients had difficulty returning to usual activities, 74% suffered some pain, none reported severe problems and 77% were able to return to work. No clinical or demographic variables were associated with poor 6-month QoL.

CONCLUSIONS

Patients with ARDS treated with ECMO generally had good QoL outcomes, similar to outcomes reported for patients managed without ECMO. With respect to QoL, VV-EMCO represents a valid treatment modality for patients with refractory ARDS.

Do-(Not-)Mechanical-Circulatory-Support Orders: Should We Ask All Cardiac Surgery Patients for Informed Consent for Post-Cardiotomy Extracorporeal Life Circulatory Support?

Post-cardiotomy extracorporeal life support (PC-ECLS) has seen a substantial increase in use over the past 10 years. PC-ECLS can be a life-saving procedure and is mostly applied in the presence of unexpected, severe cardio-respiratory complication. Despite PC-ECLS being critical in allowing for organ recovery, it is unfortunately closely connected with an unpredictable outcomes, high morbidity, and, even in the case of cardiac function improvement, potential sustained disabilities that have a life-changing impact for the patient and his or her family. Since the decision to start PC-ECLS is made in an acute setting, there is often only limited or no time for self-determined choices. Due to the major impact of the intervention, it would be highly desirable to obtain informed consent before starting PC-ECLS, since the autonomy of the patient and shared-decision making are two of the most important ethical values in modern medicine. Recent developments regarding awareness of the impacts of a prolonged intensive care stay make this a particularly relevant topic. Therefore, it would be desirable to develop a structural strategy that takes into account the likelihood of such an intervention and the wishes and preferences of the patient, and thus the related autonomy of the patient. This article proposes key points for such a strategy in the form of a PC-ECLS informed consent, a do-(not-)mechanical-circulatory-support order (D(N)MCS), and specific guidelines to determine the extent of the shared decision making. The concept presented in this article could be a starting point for improved and ethical PC-ECLS treatment and application.

One year after ICU admission for severe community-acquired pneumonia of bacterial, viral or unidentified etiology. What are the outcomes?

INTRODUCTION

Multiplex polymerase chain reaction (mPCR) for respiratory virus testing is increasingly used in community-acquired pneumonia (CAP), however data on one-year outcome in intensive care unit (ICU) patients with reference to the causative pathogen are scarce.

MATERIALS AND METHODS

We performed a single-center retrospective study in 123 ICU patients who had undergone respiratory virus testing for CAP by mPCR and with known one-year survival status. Functional status including dyspnea (mMRC score), autonomy (ADL Katz score) and need for new home-care ventilatory support was assessed at a one-year post-ICU follow-up. Mortality rates and functional status were compared in patients with CAP of a bacterial, viral or unidentified etiology one year after ICU admission.

RESULTS

The bacterial, viral and unidentified groups included 19 (15.4%), 37 (30.1%), and 67 (54.5%) patients, respectively. In multivariate analysis, one-year mortality in the bacterial group was higher compared to the viral group (HR 2.92, 95% CI 1.71-7.28, p = 0.02) and tended to be higher compared to the unidentified etiology group (p = 0.06); but no difference was found between the viral and the unidentified etiology group (p = 0.43). In 64/83 one-year survivors with a post-ICU follow-up consultation, there were no differences in mMRC score, ADL Katz score and new home-care ventilatory support between the groups (p = 0.52, p = 0.37, p = 0.24, respectively). Severe dyspnea (mMRC score = 4 or death), severe autonomy deficiencies (ADL Katz score ≤ 2 or death), and major adverse respiratory events (new home-care ventilatory support or death) were observed in 52/104 (50.0%), 47/104 (45.2%), and 65/104 (62.5%) patients, respectively; with no difference between the bacterial, viral and unidentified group: p = 0.58, p = 0.06, p = 0.61, respectively.

CONCLUSIONS

CAP of bacterial origin had a poorer outcome than CAP of viral or unidentified origin. At one-year, impairment of functional status was frequently observed, with no difference according to the etiology.

Prognostic Value of Sarcopenia for Long-Term Mortality in Extracorporeal Membrane Oxygenation for Acute Respiratory Failure

It is unclear whether sarcopenia is responsible for long-term mortality in patients who require extracorporeal membrane oxygenation (ECMO) for acute respiratory failure. We retrospectively reviewed 127 patients who underwent computed tomography imaging before initiating ECMO from June 2014 to November 2017. The patients were divided into two groups according to the skeletal muscle index (SMI): low SMI (n = 47) and high SMI (n = 80). Mean age was lower in the high SMI group than in the low SMI group (60.2 vs. 53.9 years, p = 0.002). Mean body mass index was higher in the high SMI group than in the low SMI group (21.6 vs. 24.1 kg/m, p = 0.001). The mean Charlson comorbidity index (CCI) was lower in the high SMI group than in the low SMI group (3.0 vs. 2.2, p = 0.024). After propensity score matching for age and CCI score, no differences were observed in ECMO weaning success rate or hospital mortality between the two groups. However, the 1 year mortality rate was higher in the low SMI group than in the high SMI group (70.2% vs. 46.8%, p = 0.021). Multivariate analyses showed that renal replacement therapy (odds ratio [OR] 3.99, 95% confidence interval [CI] 1.74-9.13, p = 0.001) and low SMI (OR 5.47, 95% CI 2.31-12.98, p < 0.001) were associated with 1 year mortality. Kaplan-Meier analyses revealed that a low SMI predicted mortality (χ = 13.20, p < 0.001). Sarcopenia predicted worse 1 year mortality in patients who underwent respiratory ECMO.

Persistence of patient and family experiences of critical illness

OBJECTIVE

To investigate: (1) patient and family experiences with healthcare and the intensive care unit (ICU); (2) experiences during their critical illness; (3) communication and decision making during critical illness; (4) feelings about the ICU experience; (5) impact of the critical illness on their lives; and (6) concerns about their future after the ICU.

DESIGN

Four semistructured focus group interviews with former ICU patients and family members.

SETTINGS

Multicultural community group and local hospitals containing medical/surgical ICUs.

PARTICIPANTS

Patients and family who experienced a critical illness within the previous 10 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Four separate focus groups each lasting a maximum of 150 min and consisting of a total of 21 participants were held. Focus groups were conducted using a semistructured script including six topics relating to the experience of critical illness that facilitated deduction and the sorting of data by thematic analysis into five predominant themes. The five main themes that emerged from the data were: (1) personalised stories of the critical illness; (2) communication and shared decision making, (3) adjustment to life after critical illness, (4) trust towards clinical team and relevance of cultural beliefs and (5) end-of-life decision making. Across themes, we observed a misalignment between the medical system and patient and family values and priorities.

CONCLUSIONS

The experience of critical illness of a diverse group of patients and families can remain vivid for years after ICU discharge. The identified themes reflect the strength of memory of such pivotal experiences and the importance of a narrative around those experiences. Clinicians need to be aware of the lasting effects of critical illness has on patients and families.

Oxandrolone in Patients on Venovenous Extracorporeal Membrane Oxygenation: A Case Series

Venovenous extracorporeal membrane oxygenation (VV ECMO) induces a systemic inflammatory response, which may progress to persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The anabolic steroid oxandrolone may improve the metabolic aberrations of PICS. We report our experience with 3 patients on VV ECMO who received oxandrolone after demonstrating refractory catabolism on serial nitrogen balance (NB) studies or persistent weakness. Patients in cases 1 and 3 were started on oxandrolone on VV ECMO days 45 and 29, respectively, for negative NB despite nutrition optimization. The case 2 patient started oxandrolone for persistent weakness 68 days after cannulation. All patients demonstrated improvements in NB results. One patient developed mild transaminitis while on oxandrolone, which did not alter his medication course and resolved after the medication was discontinued. The impact of oxandrolone on functional capacity varied between patients. Oxandrolone may be beneficial in persistently catabolic VV ECMO patients to improve NB results. In some patients, this may support functional recovery. Additional research is needed to identify optimal patients for therapy and to investigate the impact of oxandrolone in this population.

The Effect of Sedation on Long-Term Psychological Impairment After Extracorporeal Life Support

OBJECTIVE

This retrospective study aimed to identify the association between long-term psychological impairment and total sedation received during venovenous extracorporeal life support (VV-ECLS) for acute respiratory failure (ARF).

DESIGN

This observational retrospective study compared characteristics between patients with and without long-term psychological morbidity at long-term follow-up after VV-ECLS for ARF.

SETTING

A single institutional experience in a quaternary referral academic medical center in the United States.

PATIENTS

Patients who received VV-ECLS for ARF between January 1, 2015, and April 1, 2017, were identified for selection. Presence of psychiatric morbidity (anxiety and/or depression) was determined with the Hospital Anxiety and Depression Subscale battery at long-term follow-up.

INTERVENTIONS

No interventions were made during this retrospective observational study.

MEASUREMENTS AND MAIN RESULTS

A total of 42 patients (21 male, 21 female, median age 49 [interquartile range {IQR} 36-57]) completed a telephone interview a median of 14.6 (IQR 7.7-21.1) months after ECLS decannulation. Cohorts were defined as possessing any psychiatric morbidity (anxiety and/or depression) as defined by the Hospital Anxiety and Depression Subscale battery (n = 22 [52%]) versus no psychiatric morbidity (n = 20 [48%]) at long-term follow-up. Patients who had clinically significant psychiatric morbidity received a median of 15.0 (IQR 11.0-17.0) days of continuous intravenous sedation compared with patients who had no psychiatric morbidity, who received a median of 10.0 (IQR 6.5-13.5) days of intravenous sedation; (p = 0.02).

CONCLUSIONS

This retrospective analysis identified a significant association between the presence of long-term post-VV-ECLS psychiatric symptoms and the total number of days of intravenous sedation.