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Pisano DV, Ortoleva JP, Wieruszewski PM. Short-Term Neurologic Complications in Patients Undergoing Extracorporeal Membrane Oxygenation Support: A Review on Pathophysiology, Incidence, Risk Factors, and Outcomes. Pulm Ther 2024; 10:267-278. [PMID: 38937418 PMCID: PMC11339018 DOI: 10.1007/s41030-024-00265-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/04/2024] [Indexed: 06/29/2024] Open
Abstract
Regardless of the type, extracorporeal membrane oxygenation (ECMO) requires the use of large intravascular cannulas and results in multiple abnormalities including non-physiologic blood flow, hemodynamic perturbation, rapid changes in blood oxygen and carbon dioxide levels, coagulation abnormalities, and a significant systemic inflammatory response. Among other sequelae, neurologic complications are an important source of mortality and long-term morbidity. The frequency of neurologic complications varies and is likely underreported due to the high mortality rate. Neurologic complications in patients supported by ECMO include ischemic and hemorrhagic stroke, hypoxic brain injury, intracranial hemorrhage, and brain death. In addition to the disease process that necessitates ECMO, cannulation strategies and physiologic disturbances influence neurologic outcomes in this high-risk population. For example, the overall documented rate of neurologic complications in the venovenous ECMO population is lower, but a higher rate of intracranial hemorrhage exists. Meanwhile, in the venoarterial ECMO population, ischemia and global hypoperfusion seem to compose a higher percentage of neurologic complications. In what follows, the literature is reviewed to discuss the pathophysiology, incidence, risk factors, and outcomes related to short-term neurologic complications in patients supported by ECMO.
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Affiliation(s)
- Dominic V Pisano
- Department of Anesthesiology, Boston Medical Center, Boston, MA, USA
| | - Jamel P Ortoleva
- Department of Anesthesiology, Boston Medical Center, Boston, MA, USA
| | - Patrick M Wieruszewski
- Department of Anesthesiology, Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN, 55906, USA.
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Grotberg JC, Reynolds D, Kraft BD. Extracorporeal Membrane Oxygenation for Respiratory Failure: A Narrative Review. J Clin Med 2024; 13:3795. [PMID: 38999360 PMCID: PMC11242398 DOI: 10.3390/jcm13133795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/20/2024] [Accepted: 06/23/2024] [Indexed: 07/14/2024] Open
Abstract
Extracorporeal membrane oxygenation support for respiratory failure in the intensive care unit continues to have an expanded role in select patients. While acute respiratory distress syndrome remains the most common indication, extracorporeal membrane oxygenation may be used in other causes of refractory hypoxemia and/or hypercapnia. The most common configuration is veno-venous extracorporeal membrane oxygenation; however, in specific cases of refractory hypoxemia or right ventricular failure, some patients may benefit from veno-pulmonary extracorporeal membrane oxygenation or veno-venoarterial extracorporeal membrane oxygenation. Patient selection and extracorporeal circuit management are essential to successful outcomes. This narrative review explores the physiology of extracorporeal membrane oxygenation, indications and contraindications, ventilator management, extracorporeal circuit management, troubleshooting hypoxemia, complications, and extracorporeal membrane oxygenation weaning in patients with respiratory failure. As the footprint of extracorporeal membrane oxygenation continues to expand, it is essential that clinicians understand the underlying physiology and management of these complex patients.
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Affiliation(s)
- John C. Grotberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, MO 63131, USA; (D.R.); (B.D.K.)
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Fox S, Mehkri O, Latifi M, Krishnan S, Dill T, Duggal A. Using a Low-Flow Extracorporeal Carbon Dioxide Removal (ECCO 2 R) System in the Management of Refractory Status Asthmaticus: A Case Series. ASAIO J 2024; 70:e70-e74. [PMID: 37788483 DOI: 10.1097/mat.0000000000002064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Rescue treatments for status asthmaticus remain limited. Current literature has mainly focused on using extracorporeal membrane oxygenation (ECMO) as a primary modality of care for these patients. Low-flow extracorporeal CO 2 removal (ECCO 2 R) systems are an attractive option to improve refractory hypercapnic respiratory acidosis because of status asthmaticus. This is a retrospective case series that describes the feasibility and efficacy of the use of a low-flow ECCO 2 R device, the Hemolung Respiratory Assist System, in patients with refractory hypercapnic respiratory failure because of status asthmaticus. Eight patients were treated with the Hemolung Respiratory Assist System in eight separate locations globally. Seven (88%) of the patients survived to discharge in this case series. Both CO 2 and pH resolution were seen in 6 hours. None of the ECCO 2 R runs were stopped because of mechanical- or device-related complications. One patient necessitated transition to ECMO. Low-flow ECCO 2 R systems is an effective option for resolution of refractory hypercapnia in status asthmaticus. Use of these systems are also associated with a survival rate of close to 90% in patients with status asthmaticus.
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Affiliation(s)
- Steven Fox
- From the Department of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Omar Mehkri
- Department of Critical Care, Cleveland Clinic, Cleveland, Ohio
| | - Mani Latifi
- Department of Critical Care, Cleveland Clinic, Cleveland, Ohio
| | - Sudhir Krishnan
- Department of Critical Care, Cleveland Clinic, Cleveland, Ohio
| | - Tracey Dill
- Clinical Operations, ALung Technologies Inc., Pittsburgh, Pennsylvania
| | - Abhijit Duggal
- Department of Critical Care, Cleveland Clinic, Cleveland, Ohio
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Stommel AM, Herkner H, Kienbacher CL, Wildner B, Hermann A, Staudinger T. Effects of extracorporeal CO 2 removal on gas exchange and ventilator settings: a systematic review and meta-analysis. Crit Care 2024; 28:146. [PMID: 38693569 PMCID: PMC11061932 DOI: 10.1186/s13054-024-04927-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 04/21/2024] [Indexed: 05/03/2024] Open
Abstract
PURPOSE A systematic review and meta-analysis to evaluate the impact of extracorporeal carbon dioxide removal (ECCO2R) on gas exchange and respiratory settings in critically ill adults with respiratory failure. METHODS We conducted a comprehensive database search, including observational studies and randomized controlled trials (RCTs) from January 2000 to March 2022, targeting adult ICU patients undergoing ECCO2R. Primary outcomes were changes in gas exchange and ventilator settings 24 h after ECCO2R initiation, estimated as mean of differences, or proportions for adverse events (AEs); with subgroup analyses for disease indication and technology. Across RCTs, we assessed mortality, length of stay, ventilation days, and AEs as mean differences or odds ratios. RESULTS A total of 49 studies encompassing 1672 patients were included. ECCO2R was associated with a significant decrease in PaCO2, plateau pressure, and tidal volume and an increase in pH across all patient groups, at an overall 19% adverse event rate. In ARDS and lung transplant patients, the PaO2/FiO2 ratio increased significantly while ventilator settings were variable. "Higher extraction" systems reduced PaCO2 and respiratory rate more efficiently. The three available RCTs did not demonstrate an effect on mortality, but a significantly longer ICU and hospital stay associated with ECCO2R. CONCLUSIONS ECCO2R effectively reduces PaCO2 and acidosis allowing for less invasive ventilation. "Higher extraction" systems may be more efficient to achieve this goal. However, as RCTs have not shown a mortality benefit but increase AEs, ECCO2R's effects on clinical outcome remain unclear. Future studies should target patient groups that may benefit from ECCO2R. PROSPERO Registration No: CRD 42020154110 (on January 24, 2021).
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Affiliation(s)
- Alexandra-Maria Stommel
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
| | - Calvin Lukas Kienbacher
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Brigitte Wildner
- University Library, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alexander Hermann
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Staudinger
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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Ekechukwu N, Batra S, Orsi D, Rahmanian M, Bangar M, Mohamed A. Outcomes of Extracorporeal Life Support (ECLS) in Acute Severe Asthma: A Narrative Review. Lung 2024; 202:91-96. [PMID: 38512466 PMCID: PMC11009753 DOI: 10.1007/s00408-023-00667-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/17/2023] [Indexed: 03/23/2024]
Abstract
BACKGROUND In this narrative review we aimed to explore outcomes of extracorporeal life support (extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO2R)) as rescue therapy in patients with status asthmaticus requiring mechanical ventilation. METHODS Multiple databases were searched for studies fulfilling inclusion criteria. Articles reporting mortality and complications of ECMO and ECCO2R in mechanically ventilated patients with acute severe asthma (ASA) were included. Pooled estimates of mortality and complications were obtained by fitting Poisson's normal modeling. RESULTS Six retrospective studies fulfilled inclusion criteria thus yielding a pooled mortality rate of 17% (13-20%), pooled risk of bleeding of 22% (7-37%), mechanical complications in 26% (21-31%), infection in 8% (0-21%) and pneumothorax rate 4% (2-6%). CONCLUSION Our review identified a variation between institutions in the initiation of ECMO and ECCO2R in patients with status asthmaticus and discrepancy in the severity of illness at the time of cannulation. Despite that, mortality in these studies was relatively low with some studies reporting no mortality which could be attributed to selection bias. While ECMO and ECCO2R use in severe asthma patients is associated with complication risks, further studies exploring the use of ECMO and ECCO2R with mechanical ventilation are required to identify patients with favorable risk benefit ratio.
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Affiliation(s)
- Nneoma Ekechukwu
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sachin Batra
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Deborah Orsi
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marjan Rahmanian
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maneesha Bangar
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Amira Mohamed
- Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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Shen BH, Law AC, Wilson KC. Evidence Synthesis of Outcomes of Extracorporeal Membrane Oxygenation for Life-Threatening Asthma Exacerbations. CHEST CRITICAL CARE 2024; 2:100044. [PMID: 38605855 PMCID: PMC11008557 DOI: 10.1016/j.chstcc.2023.100044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Affiliation(s)
- Burton H Shen
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine., Boston MA
| | - Anica C Law
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine., Boston MA
| | - Kevin C Wilson
- Pulmonary Center, Boston University Chobanian & Avedisian School of Medicine., Boston MA
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Ibarra CD, Sangiovanni S, Bautista DF, Calderón-Miranda CA, Cruz GA, Fernández-Trujillo L. Use of venovenous (VV) extracorporeal membrane oxygenation (ECMO) in near-fatal asthma: a case series. Multidiscip Respir Med 2024; 19:943. [PMID: 38476128 PMCID: PMC10929514 DOI: 10.5826/mrm.2024.943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 11/09/2023] [Indexed: 03/14/2024] Open
Abstract
Introduction Status asthmaticus (SA) and near-fatal asthma (NFA) are life-threatening conditions that continue to present a management challenge for physicians. Extracorporeal Membrane Oxygenation (ECMO) has been employed as a last resort in treating these patients. Case presentation We described six patients who were admitted to the ICU for NFA and received ECMO treatment at a high-complexity institution in Cali, Colombia, between 2015 and 2019. All patients are registered in the ELSO registry. Baseline patient characteristics, arterial blood gases (ABG), ventilatory parameters, and complications were collected as specified in the ELSO registry form. Efficacy was analyzed in terms of the improvement in respiratory acidosis, the number of ventilator-free days (VFD), and a reduction in mechanical power (MP). MP, which refers to the energy associated with the mechanical forces involved in breathing and the functioning of the respiratory system, was calculated using a mathematical formula. Safety was evaluated based on the incidence of complications. After 12 hours of ECMO, we achieved a correction of respiratory acidosis, a significant decrease in all ventilatory parameters, and a reduction in MP ranging from 52.8% to 89%. There was one mortality. Among the five surviving patients, all except one, who required a tracheostomy, had a high VFD score, with a mode of 26 days, demonstrating a reduction in ventilation time. Conclusion Further randomized controlled trials are needed to fully understand the efficacy and safety profiles of ECMO in SA/NFA. MP is being widely used to achieve safer ventilation, and although more data is required, it appears to be a promising option for evaluating the risk of developing VILI and the success of the therapy.
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Affiliation(s)
- Ciro D. Ibarra
- Clinical Research Center, Fundación Valle del Lili. Cali, Colombia
| | | | - Diego F. Bautista
- Department of Critical Care Medicine, Fundación Valle del Lili, Cali, Colombia
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
| | - Camilo A. Calderón-Miranda
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
- Department of Internal Medicine, Cardiology Service, Fundación Valle del Lili, Cali, Colombia
| | - Gustavo A. Cruz
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
- Department of Anesthesiology, Fundación Valle del Lili, Cali, Colombia
| | - Liliana Fernández-Trujillo
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
- Department of Internal Medicine, Pulmonology Service, Fundación Valle del Lili, Cali, Colombia
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8
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Gayen S, Dachert S, Lashari BH, Gordon M, Desai P, Criner GJ, Cardet JC, Shenoy K. Critical Care Management of Severe Asthma Exacerbations. J Clin Med 2024; 13:859. [PMID: 38337552 PMCID: PMC10856115 DOI: 10.3390/jcm13030859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
Severe asthma exacerbations, including near-fatal asthma (NFA), have high morbidity and mortality. Mechanical ventilation of patients with severe asthma is difficult due to the complex pathophysiology resulting from severe bronchospasm and dynamic hyperinflation. Life-threatening complications of traditional ventilation strategies in asthma exacerbations include the development of systemic hypotension from hyperinflation, air trapping, and pneumothoraces. Optimizing pharmacologic techniques and ventilation strategies is crucial to treat the underlying bronchospasm. Despite optimal pharmacologic management and mechanical ventilation, the mortality rate of patients with severe asthma in intensive care units is 8%, suggesting a need for advanced non-pharmacologic therapies, including extracorporeal life support (ECLS). This review focuses on the pathophysiology of acute asthma exacerbations, ventilation management including non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV), the pharmacologic management of acute asthma, and ECLS. This review also explores additional advanced non-pharmacologic techniques and monitoring tools for the safe and effective management of critically ill adult asthmatic patients.
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Affiliation(s)
- Shameek Gayen
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Stephen Dachert
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Bilal H. Lashari
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Matthew Gordon
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Parag Desai
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Gerard J. Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
| | - Juan Carlos Cardet
- Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL 33602, USA;
| | - Kartik Shenoy
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University Hospital, Philadelphia, PA 19140, USA; (S.D.); (B.H.L.); (M.G.); (P.D.); (G.J.C.); (K.S.)
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Gayen S, Dachert S, Kim E, Gordon M, Shenoy K, Desai P. Single-institution experience of extracorporeal membrane oxygenation for near-fatal asthma. Respir Med Case Rep 2023; 46:101963. [PMID: 38187119 PMCID: PMC10770544 DOI: 10.1016/j.rmcr.2023.101963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/07/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024] Open
Abstract
Near-fatal asthma (NFA) is the most severe presentation of asthma. It is characterized by hypoxemic and hypercapnic respiratory failure requiring ventilatory assistance, including non-invasive ventilation and mechanical ventilation. However, NFA has a high mortality rate despite conventional therapy. Extracorporeal membrane oxygenation (ECMO) is a treatment modality that is increasingly being utilized as rescue therapy in patients with NFA that is refractory to mechanical ventilation. Prior analyses of the international Extracorporeal Life Support Organization (ELSO) registry data showed a survival rate of over 83% in patients placed on venovenous (VV) ECMO for NFA, but with notable rate of hemorrhagic complications. We report seven cases of adults with NFA requiring ECMO support at our large quaternary care institution between the years 2019 and 2022. All seven patients presented with respiratory failure in the setting of asthma exacerbation that progressed despite standard pharmacotherapy and mechanical ventilation. All patients survived to hospital discharge after ECMO support without hemorrhagic complications, highlighting the effectiveness and safety of ECMO when appropriately used in this population.
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Affiliation(s)
- Shameek Gayen
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Stephen Dachert
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Erica Kim
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Matthew Gordon
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Kartik Shenoy
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Parag Desai
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, USA
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10
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Xu J, Tian L, Han X. Successful treatment of near-fatal asthma with ECMO: A case report and literature review. Int J Artif Organs 2023; 46:532-536. [PMID: 37345330 DOI: 10.1177/03913988231182163] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Near-fatal asthma (NFA) can lead to severe hypercapnia and sudden cardiac arrest; however, it can be reversed by extracorporeal membrane oxygenation (ECMO). We report a case of a 37-year-old male diagnosed with NFA. After fluid rehydaration, spasmolysis, and treatment with glucocorticoid and mechanical ventilation, the patient's condition improved temporarily. However, his condition worsened rapidly, and the patient presented with progressive respiratory distress, a sharp increase in airway pressure, decreased tidal volume, and barotrauma. The patient was treated with venovenous ECMO in the prone position. Five days later, the patient was successfully weaned from ECMO. Hence, ECMO could be used for NFA at the right time to provide adequate gas exchange for patients in order to reduce lung damage and prevent death.
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Affiliation(s)
- Junxian Xu
- Department of Critical Care Medicine, Nantong Third People's Hospital, Nantong University, Nantong, China
| | - Lijun Tian
- Department of Critical Care Medicine, Nantong Third People's Hospital, Nantong University, Nantong, China
| | - Xudong Han
- Department of Critical Care Medicine, Nantong Third People's Hospital, Nantong University, Nantong, China
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11
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Kowalewski C, Schnürer P, Kopp S, Windschmitt J, Oezkur M, Kriege M, Münzel T, Kaes J, Sagoschen I, Wild J. VV-ECMO as bridge and safety net for successful therapeutic polypragmasy in a case of influenza-triggered near-fatal asthma. Clin Case Rep 2023; 11:e7709. [PMID: 37575460 PMCID: PMC10415585 DOI: 10.1002/ccr3.7709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/05/2023] [Accepted: 07/03/2023] [Indexed: 08/15/2023] Open
Abstract
Key Clinical Message In near-fatal asthma, the combination of ECMO therapy and isoflurane application via an intensive care ventilator with an anesthetic conservation device represents a therapeutic combination in seemingly hopeless clinical situations. Abstract We report a case of an adult patient with near-fatal asthma, who was implanted venovenous extracorporeal membrane oxygenation in an extern hospital before transfer to our tertiary center. After 13 days and various therapeutic approaches, including inhaled isoflurane therapy via an anesthetic-conserving device, the patient was decannulated and extubated 3 days later.
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Affiliation(s)
- Christoph Kowalewski
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
| | - Peter Schnürer
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
| | - Sabrina Kopp
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
| | - Johannes Windschmitt
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
| | - Mehmet Oezkur
- Department of Cardiac and Vascular SurgeryJohannes Gutenberg‐University MainzMainzGermany
| | - Marc Kriege
- Department of AnaesthesiologyJohannes Gutenberg‐University MainzMainzGermany
| | - Thomas Münzel
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
| | - Joachim Kaes
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
| | - Ingo Sagoschen
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
| | - Johannes Wild
- Center for Cardiology, Cardiology IJohannes Gutenberg‐University MainzMainzGermany
- German Center for Cardiovascular Research (DZHK), Partner site RheinMainMainzGermany
- Center for Thrombosis and Hemostasis (CTH)Johannes Gutenberg‐University MainzMainzGermany
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12
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Lozano-Espinosa M, Antolín-Amérigo D, Riera Del Brío J, Gordo Vidal F, Quirce S, Álvarez Rodríguez J. Extracorporeal membrane oxygenation (ECMO) and beyond in near fatal asthma: A comprehensive review. Respir Med 2023:107246. [PMID: 37245648 DOI: 10.1016/j.rmed.2023.107246] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 04/14/2023] [Accepted: 04/14/2023] [Indexed: 05/30/2023]
Abstract
The treatment of choice in severe asthma exacerbations with respiratory failure includes ventilatory support, both invasive and/or non-invasive, along with different kinds of asthma medication. Of note, the rate of mortality of patients with asthma has decreased substantially in recent years mainly due to significant advances in pharmacological treatment and other management strategies. However, the risk of death in patients with severe asthma who require invasive mechanical ventilation has been estimated between 6.5% and 10.3%. When conventional measures fail, rescue strategies, such as extracorporeal membrane oxygenation (ECMO) or extracorporeal CO2 removal (ECCO2R) may need to be implemented. While ECMO does not constitute a definitive treatment per se, it can minimize further ventilator associated lung injury (VALI) and can enable diagnostic-therapeutic maneuvers that cannot be performed without ECMO such as bronchoscopy and transfer for diagnostic imaging. Asthma is one of the diseases that is associated with excellent outcomes for patients with refractory respiratory failure requiring ECMO support, as shown by the Extracorporeal Life Support Organization (ELSO) registry. Moreover, in such situations, the use of ECCO2R for rescue has been described and utilized in both children and adults and is more widely spread in different hospitals than ECMO. In this article, we aim to review the evidence for the usefulness of extracorporeal respiratory support measures in the management of severe asthma exacerbations that lead to respiratory failure.
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Affiliation(s)
- María Lozano-Espinosa
- Servicio de Medicina Intensiva, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
| | - Darío Antolín-Amérigo
- Servicio de Alergia, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) Madrid, Spain.
| | - Jordi Riera Del Brío
- Servicio de Medicina Intensiva, Hospital Universitari Vall d'Hebron, SODIR, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Federico Gordo Vidal
- Servicio de Medicina Intensiva, Hospital Universitario Henares, Coslada, Madrid, Spain; Grupo de Investigación en Patología Crítica. Universidad Francisco de Vitoria. Pozuelo de Alarcón, Madrid, Spain
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, IdiPAZ, Madrid, Spain
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Pineda EY, Sallam M, Breuer RK, Perez GF, Wrotniak B, Swayampakula AK. Asthma Cases Treated With Inhaled Anesthetics or Extracorporeal Membrane Oxygenation: A Virtual Pediatric Systems Database Study of Outcomes. Pediatr Crit Care Med 2023:00130478-990000000-00175. [PMID: 37092833 DOI: 10.1097/pcc.0000000000003242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) and/or inhaled anesthetics (IAs) are considered in the management of asthma when refractory to conventional therapy. We aimed to compare the outcomes of these two modalities in asthma PICU care and determine associated survival to hospital discharge among patients in a United States database. DESIGN Retrospective analysis using the Virtual Pediatric Systems (VPS, LLC) database. SETTING PICUs participating in the VPS database. PATIENTS Patients less than 18 years old with diagnosis of asthma treated with IA and/or ECMO from January 2010 to December 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 221 patients were included; 149 (67%) received ECMO, 62 (28%) received IA, and 10 (5%) received both interventions. We failed to identify any difference between the ECMO and IA groups in demographics, Pediatric Index of Mortality 2 percentage, Pediatric Risk of Mortality 3 score, Pediatric Logistic Organ Dysfunction score, or pre-intervention pH and Paco2 levels. Use of ECMO versus IA was associated with lower pre-intervention Pao2 (60 torr [7.99 kPa] vs 78 torr [10.39 kPa]; p < 0.001) and higher utilization of high-frequency oscillatory ventilation. We failed to identify an association between type of intervention (IA vs ECMO) and greater odds of survival (57/62 [92%] vs 128/149 [86%]; odds ratio [OR], 1.87; 95% CI, 0.67-5.21; p = 0.23). However, these data do not exclude the possibility that IA use is associated with more than five-fold greater odds of survival. ECMO use was associated with longer duration of intervention (5 vs 1.3 d; p < 0.001) and PICU length of stay (LOS) (13 vs 7 d; p < 0.001). As expected, ECMO versus IA was also associated with greater odds of undergoing bronchoscopy (34% vs 11%; OR, 3.7; 95% CI, 1.5-9.4; p = 0.004). CONCLUSIONS In the VPS database of asthma management cases, we failed to identify an association between ECMO versus IA use and survival to hospital discharge. However, ECMO was associated with longer duration of intervention and PICU LOS.
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Affiliation(s)
- Erika Y Pineda
- 1 Department of Pediatrics, Division of Critical Care Medicine, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY
| | - Mohammad Sallam
- 2 Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Ryan K Breuer
- 1 Department of Pediatrics, Division of Critical Care Medicine, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY
| | - Geovanny F Perez
- 3 Department of Pediatrics, Division of Pulmonology, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY
| | - Brian Wrotniak
- 4 Department of Pediatrics, University at Buffalo, Buffalo, NY
| | - Anil Kumar Swayampakula
- 1 Department of Pediatrics, Division of Critical Care Medicine, John R. Oishei Children's Hospital, University at Buffalo, Buffalo, NY
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14
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Wieruszewski PM, Ortoleva JP, Cormican DS, Seelhammer TG. Extracorporeal Membrane Oxygenation in Acute Respiratory Failure. Pulm Ther 2023; 9:109-126. [PMID: 36670314 PMCID: PMC9859746 DOI: 10.1007/s41030-023-00214-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 01/09/2023] [Indexed: 01/22/2023] Open
Abstract
Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a form of mechanical life support that provides full respiratory bypass in patients with severe respiratory failure as a bridge to recovery or lung transplantation. The use of ECMO for respiratory failure and capable centers offering ECMO has expanded over the years, increasing its availability. As VV-ECMO provides an artificial mechanism for oxygenation and decarboxylation of native blood, it allows for an environment in which safer mechanical ventilatory care may be provided, allowing for treatment and resolution of underlying respiratory pathologies. Landmark clinical trials have provided a framework for better understanding patient selection criteria, resource utilization, and outcomes associated with ECMO when applied in settings of refractory respiratory failure. Maintaining close vigilance and management of complications during ECMO as well as identifying strategies post-ECMO (e.g., recovery, transplantation, etc.), are critical to successful ECMO support. In this review, we examine considerations for candidate selection for VV-ECMO, review the evidence of utilizing VV-ECMO in respiratory failure, and provide practical considerations for managing respiratory ECMO patients, including complication identification and management, as well as assessing for the ability to separate from ECMO support and the procedures for decannulation.
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Affiliation(s)
- Patrick M. Wieruszewski
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA ,Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
| | - Jamel P. Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA USA
| | - Daniel S. Cormican
- Division of Cardiothoracic Anesthesiology, Allegheny General Hospital, Pittsburg, PA USA
| | - Troy G. Seelhammer
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
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15
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Zakrajsek JK, Min SJ, Ho PM, Kiser TH, Kannappan A, Sottile PD, Allen RR, Althoff MD, Reynolds PM, Moss M, Burnham EL, Mikkelsen ME, Vandivier RW. Extracorporeal Membrane Oxygenation for Refractory Asthma Exacerbations With Respiratory Failure. Chest 2023; 163:38-51. [PMID: 36191634 PMCID: PMC10354700 DOI: 10.1016/j.chest.2022.09.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Asthma exacerbations with respiratory failure (AERF) are associated with hospital mortality of 7% to 15%. Extracorporeal membrane oxygenation (ECMO) has been used as a salvage therapy for refractory AERF, but controlled studies showing its association with mortality have not been performed. RESEARCH QUESTION Is treatment with ECMO associated with lower mortality in refractory AERF compared with standard care? STUDY DESIGN AND METHODS This is a retrospective, epidemiologic, observational cohort study using a national, administrative data set from 2010 to 2020 that includes 25% of US hospitalizations. People were included if they were admitted to an ECMO-capable hospital with an asthma exacerbation, and were treated with short-acting bronchodilators, systemic corticosteroids, and invasive ventilation. People were excluded for age < 18 years, no ICU stay, nonasthma chronic lung disease, COVID-19, or multiple admissions. The main exposure was ECMO vs No ECMO. The primary outcome was hospital mortality. Key secondary outcomes were ICU length of stay (LOS), hospital LOS, time receiving invasive ventilation, and total hospital costs. RESULTS The study analyzed 13,714 patients with AERF, including 127 with ECMO and 13,587 with No ECMO. ECMO was associated with reduced mortality in the covariate-adjusted (OR, 0.33; 95% CI, 0.17-0.64; P = .001), propensity score-adjusted (OR, 0.36; 95% CI, 0.16-0.81; P = .01), and propensity score-matched models (OR, 0.48; 95% CI, 0.24-0.98; P = .04) vs No ECMO. Sensitivity analyses showed that mortality reduction related to ECMO ranged from OR 0.34 to 0.61. ECMO was also associated with increased hospital costs in all three models (P < .0001 for all) vs No ECMO, but not with decreased ICU LOS, hospital LOS, or time receiving invasive ventilation. INTERPRETATION ECMO was associated with lower mortality and higher hospital costs, suggesting that it may be an important salvage therapy for refractory AERF following confirmatory clinical trials.
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Affiliation(s)
- Jonathan K Zakrajsek
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sung-Joon Min
- Division of Health Care Policy and Research, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P Michael Ho
- Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Tyree H Kiser
- Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Arun Kannappan
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Meghan D Althoff
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Paul M Reynolds
- Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ellen L Burnham
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Mark E Mikkelsen
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - R William Vandivier
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO; Colorado Pulmonary Outcomes Research Group (CPOR), Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
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16
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Custer CM, O'Neil ER, Paskaradevan J, Rissmiller BJ, Gazzaneo MC. Children with Near-Fatal Asthma: The Use of Inhaled Volatile Anesthetics and Extracorporeal Membrane Oxygenation. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2022; 35:170-173. [PMID: 36537704 DOI: 10.1089/ped.2022.0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background and Purpose: The use of extracorporeal membrane oxygenation (ECMO) has been described for near-fatal asthma that continues to be refractory despite maximal medical therapy. Methods: Patients admitted to the pediatric intensive care unit at Texas Children's Hospital from 2012 to 2020 with the diagnosis of asthma who were supported on ECMO or isoflurane were included in the study. Patient demographics, medication usage, and complications were compared between the case group (ECMO, n = 12) and the control group (isoflurane only, n = 8). Results: All patients survived to discharge. ECMO patients received shorter durations of albuterol (12 versus 104 h, P = 0.0002) and terbutaline (13.3 versus 31.5 h, P = 0.0250). There were no differences in complication rates between the 2 groups. Conclusion: ECMO is a reasonable and safe support method for patients with near-fatal asthma and may lead to less bronchodilator medication exposure when compared with inhaled volatile anesthetic use.
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Affiliation(s)
- Chasity M Custer
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Erika R O'Neil
- Department of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Brian J Rissmiller
- Department of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Maria C Gazzaneo
- Department of Pediatric Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA.,Department of Pulmonology, Baylor College of Medicine, Houston, Texas, USA
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17
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Gill B, Bartock JL, Damuth E, Puri N, Green A. Case report: Isoflurane therapy in a case of status asthmaticus requiring extracorporeal membrane oxygenation. Front Med (Lausanne) 2022; 9:1051468. [PMID: 36425104 PMCID: PMC9679515 DOI: 10.3389/fmed.2022.1051468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/19/2022] [Indexed: 08/15/2023] Open
Abstract
Volatile anesthetics have been described as a rescue therapy for patients with refractory status asthmaticus (SA), and the use of isoflurane for this indication has been reported since the 1980s. Much of the literature reports good outcomes when inhaled isoflurane is used as a rescue therapy for patients for refractory SA. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is a mode of mechanical circulatory support that is usually employed as a potentially lifesaving intervention in patients who have high risk of mortality, primarily for underlying pulmonary pathology. VV ECMO is usually only considered in cases where patients gas exchange cannot be satisfactorily maintained by conventional therapy and mechanical ventilation strategies. We report the novel use of isoflurane delivered systemically as treatment for severe refractory SA in a patient on VV ECMO. A 51-year-old male with a history of asthma was transferred from another institution for management of severe SA. He was intubated at the referring hospital after failing non-invasive ventilation. Initial arterial blood gas (ABG) showed pH 7.21, partial pressure of carbon dioxide (PCO2) >95 mmHg, and partial pressure of oxygen (PaO2) 60 mmHg. VV ECMO was initiated on hospital day (HD) 1 due to refractory respiratory acidosis. After ECMO initiation, acid-base status improved, however, severe bronchospasm persisted and intrinsic positive end expiratory pressure (PEEP) was measured at 18 cm H2O. Systemic paralysis was employed, respiratory rate (RR) was reduced to 4 breaths per minute. This degree of bronchospasm did not allow for ECMO weaning. On HD 5, the patient received systemic isoflurane via the ECMO circuit for 20 h. The following morning, intrinsic PEEP was 4 cm H2O, and wheezing improved. He was decannulated from VV ECMO on HD 10 and extubated on HD 17. Inhaled isoflurane therapy in patients on VV ECMO for refractory SA has shown good results, but requires delivery of the medication via anesthesia ventilators. Our case highlights an effective alternative, systemic delivery of anesthetic via the ECMO circuit, as it is often difficult and dangerous to transport these patients to the operating room (OR) or have an intensive care unit (ICU) room adjusted to accommodate an anesthesia ventilator.
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Affiliation(s)
- Brendan Gill
- Department of Critical Care Medicine, Cooper University Health Care, Camden, NJ, United States
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18
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Extracorporeal Life Support for Status Asthmaticus: Early Outcomes in Teens and Young Adults. ASAIO J 2022; 68:1305-1311. [PMID: 36194100 DOI: 10.1097/mat.0000000000001644] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Extracorporeal life support (ECLS) may be life saving for patients with status asthmaticus (SA), a difficult-to-treat, severe subset of asthma. Contemporary ECLS outcomes for SA in teens and young adults are not well described. The Extracorporeal Life Support Organization (ELSO) Registry was reviewed (2009-2019) for patients (15-35 years) with a primary diagnosis of SA. In-hospital mortality and complications were described. Multivariable logistic regression was used to identify independent risk factors for hospital mortality. Overall, 137 patients, (26 teens and 111 young adults; median age 25 years) were included. Extracorporeal life support utilization for SA sharply increased in 2010, coinciding with increased ECLS utilization overall. Median ECLS duration and length of stay were 97 hours and 11 days, respectively. In-hospital mortality and major complication rates were 10% and 11%, respectively. Nonsurvivors were more likely to have experienced ECLS complications, compared to survivors (86% vs. 42%, p = 0.003). Independent risk factors for in-hospital mortality included pre-ECLS arrest and any renal and/or neurologic complication. Prospective studies designed to evaluate complications and subsequent failure to rescue may help optimize quality improvement efforts.
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19
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Wang K, Gartman CH, Zhou EY, Horak J, Augoustides JG, Gebhardt BR, Jain A, Coleman SR, Fernando RJ. Severe Bronchospasm During Separation from Cardiopulmonary Bypass: Diagnosis, Etiology, and Treatment. J Cardiothorac Vasc Anesth 2022; 36:3964-3972. [PMID: 35909041 DOI: 10.1053/j.jvca.2022.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Kelvin Wang
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Charles H Gartman
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth Yaxi Zhou
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jiri Horak
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian R Gebhardt
- Department of Anesthesiology and Perioperative Medicine, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Ankit Jain
- Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Scott R Coleman
- Department of Anesthesiology, Cardiothoracic Section, Medical Center Boulevard, Wake Forest School of Medicine, Winston Salem, NC 27157-1009, USA
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Medical Center Boulevard, Wake Forest School of Medicine, Winston Salem, NC 27157-1009, USA.
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20
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Zhai H, Huang L, Li T, Hu X, Duan D, Wu P. A successful extracorporeal cardiopulmonary resuscitation for severe status asthmaticus with an ultra-long cardiac arrest. Am J Emerg Med 2022; 62:145.e5-145.e8. [PMID: 36100495 DOI: 10.1016/j.ajem.2022.08.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/05/2022] [Accepted: 08/28/2022] [Indexed: 10/14/2022] Open
Abstract
The mortality of severe asthma with cardiac arrest is still close to 100% even if it is treated with conventional cardiopulmonary resuscitation (CCPR). Extracorporeal cardiopulmonary resuscitation (ECPR) has been widely accepted as an alternative method when CCPR is futile. However, the maximum "low-flow" duration has not been well defined. Here, we reported a 55-year-old male with severe asthma with cardiac arrest, who was successfully treated with ECPR after 100 min of ultra-long CCPR. He was withdrawn from extracorporeal membrane oxygenator and ventilator at 72 h and 14 days after admission respectively and was discharged without permanent neurologic sequelae. This case illustrates the critical role of ECPR as a last resort in near-fatal asthma. For such patients with bystander, starting ECPR after >60 min of CCPR can still obtain satisfactory prognoses.
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Affiliation(s)
- Hu Zhai
- Department of Heart Center, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin 300170, China; Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, China; Artificial Cell Engineering Technology Research Center, Tianjin, China; Tianjin Institute of Hepatobiliary Disease, Tianjin, China.
| | - Lei Huang
- Department of Heart Center, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin 300170, China; Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, China
| | - Tong Li
- Department of Heart Center, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin 300170, China; Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, China; Artificial Cell Engineering Technology Research Center, Tianjin, China; Tianjin Institute of Hepatobiliary Disease, Tianjin, China.
| | - Xiaomin Hu
- Department of Heart Center, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin 300170, China; Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, China
| | - Dawei Duan
- Department of Heart Center, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin 300170, China; Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, China
| | - Peng Wu
- Department of Heart Center, The Third Central Hospital of Tianjin, 83 Jintang Road, Hedong District, Tianjin 300170, China; Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, China
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21
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Sakurai K, Singhal N. Extracorporeal membrane oxygenation in children: A brief review. J Paediatr Child Health 2022; 58:1525-1531. [PMID: 35932281 PMCID: PMC9545746 DOI: 10.1111/jpc.16151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 05/12/2022] [Accepted: 07/21/2022] [Indexed: 01/24/2023]
Abstract
With the advancement in technology and increasing familiarity, the use of extracorporeal membrane oxygenation (ECMO) has expanded in the past decade. Although ECMO can be lifesaving for critically ill children, it is an invasive therapy associated with complications that may necessitate rehabilitation and long-term follow-up. Paediatric clinicians play an essential role in managing these children, especially after the acute phase of their illness. This review provides an overview of ECMO and will provide a basic understanding of ECMO and its principles.
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Affiliation(s)
- Ken Sakurai
- Department of Paediatric Intensive CareThe Children's Hospital at WestmeadSydneyNew South WalesAustralia
| | - Nitesh Singhal
- Department of Paediatric Intensive CareThe Children's Hospital at WestmeadSydneyNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNSWAustralia
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22
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Evaluation and Management of Asthma and Chronic Obstructive Pulmonary Disease Exacerbation in the Emergency Department. Emerg Med Clin North Am 2022; 40:539-563. [DOI: 10.1016/j.emc.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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23
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Prevention and Treatment of Asthma Exacerbations in Adults. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2578-2586. [PMID: 34246434 DOI: 10.1016/j.jaip.2021.05.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 05/20/2021] [Accepted: 05/20/2021] [Indexed: 02/08/2023]
Abstract
Asthma exacerbations are major contributors to disease morbidity in patients of all ages. To develop strategies that reduce the disease burden from exacerbations, it is helpful to review current concepts about the risk factors for asthma attacks and current approaches for prevention and treatment. Multiple factors contribute as risks and to the development of asthma exacerbations, including allergic and infectious processes. Viral respiratory infections, primarily from rhinoviruses, are the dominant exacerbating cause for most asthma patients. Allergic sensitization and allergen exposure contribute directly and enhance susceptibility for respiratory viral infections. Respiratory viruses infect airway epithelium to promote underlying type 2 inflammation with eosinophils, the predominant cellular component of increased inflammation. Deficiencies of antiviral interferon responses and generation have been identified that increase susceptibility to viral infections in asthma. Exacerbation treatment focuses on reducing airflow obstruction and suppressing inflammation, followed by improving long-term asthma control. Increasing concern exists regarding the side effects associated with frequent systemic corticosteroid use. A major advance has been the selective use of biologics to prevent exacerbations, primarily in patients with existing type 2 inflammation. Future research to prevent exacerbations is being directed toward antiviral activity and a more encompassing regulation of underlying airway inflammation.
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24
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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Qiu C, Li T, Wei G, Xu J, Yu W, Wu Z, Li D, He Y, Chen T, Zhang J, He X, Hu J, Fang J, Zhang H. Hemorrhage and venous thromboembolism in critically ill patients with COVID-19. SAGE Open Med 2021; 9:20503121211020167. [PMID: 34104439 PMCID: PMC8170290 DOI: 10.1177/20503121211020167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/03/2021] [Indexed: 12/28/2022] Open
Abstract
Objective: The majority of patients with COVID-19 showed mild symptoms. However,
approximately 5% of them were critically ill and require intensive care unit
admission for advanced life supports. Patients in the intensive care unit
were high risk for venous thromboembolism and hemorrhage due to the
immobility and anticoagulants used during advanced life supports. The aim of
the study was to report the incidence and treatments of the two
complications in such patients. Method: Patients with COVID-19 (Group 1) and patients with community-acquired
pneumonia (Group 2) that required intensive care unit admission were
enrolled in this retrospective study. Their demographics, laboratory
results, ultrasound findings and complications such as venous
thromboembolism and hemorrhage were collected and compared. Results: Thirty-four patients with COVID-19 and 51 patients with community-acquired
pneumonia were included. The mean ages were 66 and 63 years in Groups 1 and
2, respectively. Venous thromboembolism was detected in 6 (18%) patients
with COVID-19 and 18 (35%) patients with community-acquired pneumonia
(P = 0.09). The major type was distal deep venous thrombosis. Twenty-one
bleeding events occurred in 12 (35%) patients with COVID-19 and 5 bleeding
events occurred in 5 (10%) patients with community-acquired pneumonia,
respectively (P = 0.01). Gastrointestinal system was the most common source
of bleeding. With the exception of one death due to intracranial bleeding,
blood transfusion with or without surgical/endoscopic treatments was able to
manage the bleeding in the remaining patients. Multivariable logistic
regression showed increasing odds of hemorrhage with extracorporeal membrane
oxygenation (odds ratio: 13.9, 95% confidence interval: 4.0–48.1) and
COVID-19 (odds ratio: 4.7, 95% confidence interval: 1.2–17.9). Conclusion: Venous thromboembolism and hemorrhage were common in both groups. The
predominant type of venous thromboembolism was distal deep venous
thrombosis, which presented a low risk of progression. COVID-19 and
extracorporeal membrane oxygenation were risk factors for hemorrhage. Blood
transfusion with or without surgical/endoscopic treatments was able to
manage it in most cases.
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Affiliation(s)
- Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tong Li
- Department of Emergency, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Guoqing Wei
- Department of Hematology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jun Xu
- Intensive Care Unit, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wenqiao Yu
- Intensive Care Unit, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Donglin Li
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yangyan He
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tianchi Chen
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jingchen Zhang
- Department of Emergency, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xujian He
- Department of Emergency, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jia Hu
- Department of Emergency, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junjun Fang
- Intensive Care Unit, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Extracorporeal Carbon Dioxide Removal in the Treatment of Status Asthmaticus. Crit Care Med 2021; 48:e1226-e1231. [PMID: 33031151 DOI: 10.1097/ccm.0000000000004645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Venovenous extracorporeal carbon dioxide removal may be lifesaving in the setting of status asthmaticus. DESIGN Retrospective review. SETTING Medical ICU. PATIENTS Twenty-six adult patients with status asthmaticus treated with venovenous extracorporeal carbon dioxide removal. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic data and characteristics of current and prior asthma treatments were obtained from the electronic medical record. Mechanical ventilator settings, arterial blood gases, vital signs, and use of vasopressors were collected from the closest time prior to cannulation and 24 hours after initiation of extracorporeal carbon dioxide removal. Extracorporeal carbon dioxide removal settings, including blood flow and sweep gas flow, were collected at 24 hours after initiation of extracorporeal carbon dioxide removal. Outcome measures included rates of survival to hospital discharge, ICU and hospital lengths of stay, duration of invasive mechanical ventilation and extracorporeal carbon dioxide removal support, and complications during extracorporeal carbon dioxide removal. Following the initiation of extracorporeal carbon dioxide removal, blood gas values were significantly improved at 24 hours, as were peak airway pressures, intrinsic positive end-expiratory pressure, and use of vasopressors. Survival to hospital discharge was 100%. Twenty patients (76.9%) were successfully extubated while receiving extracorporeal carbon dioxide removal support; none required reintubation. The most common complication was cannula-associated deep venous thrombosis (six patients, 23.1%). Four patients (15.4%) experienced bleeding that required a transfusion of packed RBCs. CONCLUSIONS In the largest series to date, use of venovenous extracorporeal carbon dioxide removal in patients with status asthmaticus can provide a lifesaving means of support until the resolution of the exacerbation, with an acceptably low rate of complications. Early extubation in select patients receiving extracorporeal carbon dioxide removal is safe and feasible and avoids the deleterious effects of positive-pressure mechanical ventilation in this patient population.
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 314] [Impact Index Per Article: 104.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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McLellan T, Patvardhan C, Rassl D, Jenkins HS, Knolle M, Thillai M. Asthma, ECMO and eosinophils. Thorax 2021; 76:737-739. [PMID: 33495316 DOI: 10.1136/thoraxjnl-2020-216052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/13/2020] [Accepted: 12/14/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Tom McLellan
- Interstitial Lung Disease Service, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Chinmay Patvardhan
- Critical Care Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Doris Rassl
- Department of Histopathology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK
| | - Huw Steven Jenkins
- Respiratory Medicine, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK
| | - Martin Knolle
- Asthma & Allergy Service, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK.,Department of Medicine, Cambridge University, Cambridge, Cambridgeshire, UK
| | - Muhunthan Thillai
- Interstitial Lung Disease Service, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Cambridgeshire, UK.,Department of Medicine, Cambridge University, Cambridge, Cambridgeshire, UK
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Kim JH, Pieri M, Landoni G, Scandroglio AM, Calabrò MG, Fominskiy E, Lembo R, Heo MH, Zangrillo A. Venovenous ECMO treatment, outcomes, and complications in adults according to large case series: A systematic review. Int J Artif Organs 2020; 44:481-488. [DOI: 10.1177/0391398820975408] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Venovenous extracorporeal membrane oxygenation (VV ECMO) has gained popularity for the treatment of refractory respiratory failure during and after the 2009 influenza pandemic, and still represents a precious therapeutic resource for severe novel coronavirus 2019 infection. However, most of the published studies are small case series, and only two randomized trials exist in literature. Aim: Aim of this systematic review is to describe trends in VV ECMO treatment outcomes according to large studies only. Methods: We searched and included studies with more than 100 VV ECMO cases dated up to August 1st, 2019. Results: Thirty-three studies published in the period 2011–2019 met inclusion criteria, for a total of 12,860 patients (age 46.3 ± 17.4 years). ARDS was mainly by pneumonia, in 3126 (37%) cases; further 401(7%) patients had H1N1 Influenza A infection. Cannulation-related complications occurred in 502 (7%) cases. Weighted mean (95% confidence interval) of VV ECMO duration was 8.9 (8.7–9.1) days, and ICU stay was 23.6 (22.4–24.8) days. Mortality at the longest follow up available was 40%. Data collection in 70% of the studies had a duration of >5 years. Conclusion: This study reveals the characteristics of large case VV ECMO studies.
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Affiliation(s)
- Jun Hyun Kim
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Grazia Calabrò
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Min Hee Heo
- Department of Anesthesiology and Pain Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Acute severe asthma requiring invasive mechanical ventilation in the era of modern resuscitation techniques: A 10-year bicentric retrospective study. PLoS One 2020; 15:e0240063. [PMID: 33007018 PMCID: PMC7531794 DOI: 10.1371/journal.pone.0240063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/17/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Patients with acute severe asthma (ASA) may in rare cases require invasive mechanical ventilation (IMV). However, recent data on this issue are lacking. Materials and methods In this retrospective and bicentric study conducted on a 10 year period, we investigate the in-hospital mortality in patients with ASA requiring IMV. We compare this mortality to that of patients with other types of respiratory distress using a standardized mortality ratio (SMR) model. Results Eighty-one episodes of ASA requiring IMV were evaluated. Factors significantly associated with in-hospital mortality were cardiac arrest on day of admission, cardiac arrest as the reason for intubation, absence of decompensation risk factors, need for renal replacement therapy on day of admission, and intubation in pre-hospital setting. Non-survivors had higher SAPS II, SOFA, creatinine and lactate levels as well as lower blood pressure, pH, and HCO3 on day of admission. In-hospital mortality was 15% (n = 12). Compared to a reference population of 2,670 patients, the SMR relative to the SAPS II was very low at 0.48 (95% CI, 0.25–0.84). The only factor independently associated with in-hospital mortality was cardiac arrest on day of admission. In-hospital mortality was 69% in patients with cardiac arrest on day of admission and 4% in others (p < 0.01). Salvage therapies were given to 7 patients, sometimes in combination with each other: ECMO (n = 6), halogenated gas (n = 1) and anti-IL5 antibody (n = 1). Death occurred in only 2 of these 7 patients, both of whom had cardiac arrest on day of admission. Conclusion Nowadays, the mortality of patients with ASA requiring IMV is low. Death is due to multi-organ failure, with cardiac arrest on day of admission being the most important risk factor. In patients who did not have cardiac arrest on day of admission the mortality is even lower (4%) which allows an aggressive management.
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31
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Badulak JH, Shinar Z. Extracorporeal Membrane Oxygenation in the Emergency Department. Emerg Med Clin North Am 2020; 38:945-959. [PMID: 32981628 DOI: 10.1016/j.emc.2020.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a mechanical way to provide oxygenation, ventilation, and perfusion to patients with severe cardiopulmonary failure. Extracorporeal cardiopulmonary resuscitation (ECPR) describes the use of ECMO during cardiac arrest. ECPR requires an organized approach to resuscitation, cannula insertion, and pump initiation. Selecting the right patients for ECPR is an important aspect of successful programs. A solid understanding of the components of the ECMO circuit is critical to troubleshooting problems. Current evidence suggests a substantial benefit of ECPR compared with traditional CPR for refractory cardiac arrest but is limited by lack of randomized trials to date.
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Affiliation(s)
- Jenelle H Badulak
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Emergency Medicine, University of Washington, Harborview Medical Center, Box 359702, 325 Ninth Avenue, Seattle, WA 98104-2499, USA.
| | - Zachary Shinar
- Department of Emergency Medicine, Sharp Memorial Hospital, 7901 Frost Street, San Diego, CA 92130, USA. https://twitter.com/ZackShinar
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Warren A, Chiu YD, Villar SS, Fowles JA, Symes N, Barker J, Camporota L, Harvey C, Ledot S, Scott I, Vuylsteke A. Outcomes of the NHS England National Extracorporeal Membrane Oxygenation Service for adults with respiratory failure: a multicentre observational cohort study. Br J Anaesth 2020; 125:259-266. [PMID: 32736826 DOI: 10.1016/j.bja.2020.05.065] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is increasingly used to support adults with severe respiratory failure refractory to conventional measures. In 2011, NHS England commissioned a national service to provide ECMO to adults with refractory acute respiratory failure. Our aims were to characterise the patients admitted to the service, report their outcomes, and highlight characteristics potentially associated with survival. METHODS An observational cohort study was conducted of all patients treated by the NHS England commissioned ECMO service between December 1, 2011 and December 31, 2017. Analysis was conducted according to a prespecified protocol (NCT: 03979222). Data are presented as median [inter-quartile range, IQR]. RESULTS A total of 1205 patients were supported with ECMO during the study period; the majority (n=1150; 95%) had veno-venous ECMO alone. The survival rate at ECMO ICU discharge was 74% (n=887). Survivors had a lower median age (43 yr [32-52]), compared with non-survivors (49 y [39-60]). Increased severity of hypoxaemia at time of decision-to-cannulate was associated with a lower probability of survival: survivors had a median Sao2 of 90% (84-93%; median Pao2/Fio2, 9.4 kPa [7.7-12.6]), compared with non-survivors (Sao2 88% [80-92%]; Pao2/Fio2 ratio: 8.5 kPa [7.1-11.5]). Patients requiring ECMO because of asthma were more likely to survive (95% survival rate (95% CI, 91-99%), compared with a survival of 71% (95% CI, 69-74%) in patients with respiratory failure attributable to other diagnoses. CONCLUSION A national ECMO service can achieve good short-term outcomes for patients with undifferentiated respiratory failure refractory to conventional management. CLINICAL TRIAL REGISTRATION NCT03979222.
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Affiliation(s)
- Alex Warren
- Division of Anaesthesia, Department of Medicine, School of Clinical Medicine, University of Cambridge, Cambridge, UK; Critical Care Unit, Royal Papworth Hospital, Cambridge, UK
| | - Yi-Da Chiu
- MRC Biostatistics Unit, Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK; Clinical Trials Unit, Royal Papworth Hospital, Cambridge, UK
| | - Sofía S Villar
- MRC Biostatistics Unit, Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jo-Anne Fowles
- Critical Care Unit, Royal Papworth Hospital, Cambridge, UK
| | - Nicola Symes
- Highly Specialised Services, NHS England, London, UK
| | - Julian Barker
- Cardiothoracic Critical Care Unit, Wythenshawe Hospital, Manchester, UK
| | - Luigi Camporota
- Department of Critical Care, Guy's & St Thomas' Hospitals, London, UK; Division of Asthma, Allergy and Lung Biology, King's College London, London, UK
| | - Chris Harvey
- University Hospitals of Leicester, Leicester, UK
| | - Stephane Ledot
- Adult Intensive Care Unit, Royal Brompton & Harefield Hospitals, London, UK
| | - Ian Scott
- Intensive Care Unit, Aberdeen Royal Infirmary, Aberdeen, UK
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Yeo HJ, Kim YS, Kim D, Cho WH. Risk factors for complete recovery of adults after weaning from veno-venous extracorporeal membrane oxygenation for severe acute respiratory failure: an analysis from adult patients in the Extracorporeal Life Support Organization registry. J Intensive Care 2020; 8:64. [PMID: 32839669 PMCID: PMC7439234 DOI: 10.1186/s40560-020-00480-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/10/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND As extracorporeal membrane oxygenation (ECMO) has been widely used, the patient quality of life following ECMO termination has become an important issue as same as the patient's survival. To date, the factors affecting complete recovery of adult survivors from ECMO have not been investigated. METHODS Data from adult patients in the Extracorporeal Life Support Organization registry who received veno-venous ECMO between 2012 and 2017 were analyzed. Multivariate logistic regression analyses were conducted. RESULTS In total, 6536 patients with 242,183 days of veno-venous ECMO were reviewed. The overall survival to discharge rate after weaning from ECMO was 89.7% (n = 5861), and 10.3% (n = 675) of the patients died during hospitalization. The discharge location varied as follows: 33.7% (n = 1976) returned home, 23.4% (n = 1369) were transferred to a referral hospital, 41.8% (n = 2447) required hospital services, and 0.6% (n = 36) were discharged to other places. The patients were divided into two groups according to the discharge location: a complete recovery group (n = 1976) and a partial recovery group (n = 3885). In the multivariate analyses, age (≥ 65 years) (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.59-0.87, p = 0.001), cardiac arrest before ECMO (OR 0.76, 95% CI 0.60-0.96, p = 0.021), vasopressor use (OR 0.73, 95% CI 0.64-0.83, p < 0.001), renal replacement therapy (OR 0.40, 95% CI 0.28-0.57, p < 0.001), ECMO-related complications (OR 0.76, 95% CI 0.67-0.85, p < 0.001), and long-term ECMO support (≥ 2 weeks) (OR 0.42, 95% CI 0.37-0.48, p < 0.001) were significantly associated with complete recovery. CONCLUSION Complete recovery after veno-venous ECMO support is associated with the patient's baseline condition, ECMO duration, and ECMO-related complications. Respiratory ECMO should aim to increase both the survival and the quality of life after weaning from ECMO.
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Affiliation(s)
- Hye Ju Yeo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Geumo-ro 20, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do 626-770 Republic of Korea
| | - Yun Seong Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Geumo-ro 20, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do 626-770 Republic of Korea
| | - Dohyung Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | | | - Woo Hyun Cho
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Geumo-ro 20, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do 626-770 Republic of Korea
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Naoum EE, Chalupka A, Haft J, MacEachern M, Vandeven CJM, Easter SR, Maile M, Bateman BT, Bauer ME. Extracorporeal Life Support in Pregnancy: A Systematic Review. J Am Heart Assoc 2020; 9:e016072. [PMID: 32578471 PMCID: PMC7670512 DOI: 10.1161/jaha.119.016072] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background The use of extracorporeal life support (ECLS) has expanded to include unique populations such as peripartum women. This systematic review aims to (1) quantify the number of cases and indications for ECLS in women during the peripartum period reported in the literature and (2) report maternal and fetal complications and outcomes associated with peripartum ECLS. Methods and Results This review was registered in PROSPERO (CRD42018108142). MEDLINE, Embase, and CINAHL were searched for case reports, case series, and studies reporting cases of ECLS during the peripartum period that reported one or more of the following outcomes: maternal survival, maternal complications, fetal survival, and/or fetal complications. Qualitative assessment of 221 publications evaluated the number of cases, clinical details, and maternal and fetal outcomes of ECLS during the peripartum period. There were 358 women included and 68 reported fetal outcomes in cases where the mother was pregnant at the time of cannulation. The aggregate maternal survival at 30 days was 270 (75.4%) and at 1 year was 266 (74.3%); fetal survival was 44 (64.7%). The most common indications for ECLS overall in pregnancy included acute respiratory distress syndrome 177 (49.4%), cardiac failure 67 (18.7%), and cardiac arrest 57 (15.9%). The most common maternal complications included mild to moderate bleeding 66 (18.4%), severe bleeding requiring surgical intervention 48 (13.4%), and intracranial neurologic morbidity 19 (5.3%). The most commonly reported fetal complications included preterm delivery 33 (48.5%) and neonatal intensive care unit admission 19 (27.9%). Conclusions Reported rates of survival in ECLS in pregnant and postpartum women are high and major complications relatively low.
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Affiliation(s)
- Emily E. Naoum
- Department of AnesthesiologyUniversity of MichiganAnn ArborMI
| | - Andrew Chalupka
- Department of Anesthesia, Critical Care and Pain MedicineMassachusetts General HospitalBostonMA
| | - Jonathan Haft
- Department of Cardiac SurgeryUniversity of MichiganAnn ArborMI
| | - Mark MacEachern
- Taubman Health Sciences LibraryUniversity of MichiganAnn ArborMI
| | - Cosmas J. M. Vandeven
- Department of Obstetrics and GynecologyMaternal‐Fetal MedicineUniversity of MichiganAnn ArborMI
| | - Sarah Rae Easter
- Division of Maternal‐Fetal MedicineDepartment of Obstetrics and GynecologyBrigham and Women’s HospitalBostonMA
| | - Michael Maile
- Department of AnesthesiologyUniversity of MichiganAnn ArborMI
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of MedicineDepartment of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalBostonMA
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Lang Y, Zheng Y, Hu X, Xu L, Luo Z, Duan D, Wu P, Huang L, Gao W, Ma Q, Ning M, Li T. Extracorporeal membrane oxygenation for near fatal asthma with sudden cardiac arrest. J Asthma 2020; 58:1216-1220. [PMID: 32543251 DOI: 10.1080/02770903.2020.1781164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Near fatal asthma is a life-threatening disorder that requires mechanical ventilation. Near fatal asthma and COPD with sudden cardiac arrest can worsen the outcomes. Previous studies demonstrated that ECMO is a live-saving measure for near fatal asthma that does not respond to traditional treatment. CASE STUDY A patient with near fatal asthma (NFA) and COPD presented with high airway resistance, life-threatening acidemia and severe hypoxemia that failed to respond to conventional therapy. His hospital course was complicated by sudden cardiac arrest when preparing to initiate V-V mode extracorporeal membrane oxygenation (ECMO). The mode immediately changed from V-V to V-A, then to V-AV and finally to V-V mode in order to improve cardiac function and promote recovery of lung function. RESULTS On the sixth day, ECMO was removed and on the ninth day, he was extubated and transferred to the ward. Finally, the patient was discharged home on the nineteenth day after admission to be followed up in the pulmonary clinic. CONCLUSIONS The early application of ECMO and mode changing plausibly resulted in dramatic improvement in gas exchange and restoration of cardiac function. This case illustrates the critical role of ECMO mode changing as salvage therapy in NFA and COPD with sudden cardiac arrest.
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Affiliation(s)
- Yuheng Lang
- Department of Heart Centre, Tianjin Third Central Hospital, Tianjin, P.R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, P.R. China.,Key Laboratory of Artificial Cell, Tianjin Third Central Hospital, Tianjin, P.R. China.,Artificial Cell Engineering Technology Research Center, Tianjin, P.R. China
| | - Yue Zheng
- Department of Heart Centre, Tianjin Third Central Hospital, Tianjin, P.R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, P.R. China.,Key Laboratory of Artificial Cell, Tianjin Third Central Hospital, Tianjin, P.R. China.,Artificial Cell Engineering Technology Research Center, Tianjin, P.R. China
| | - Xiaomin Hu
- Department of Heart Centre, Tianjin Third Central Hospital, Tianjin, P.R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, P.R. China.,Key Laboratory of Artificial Cell, Tianjin Third Central Hospital, Tianjin, P.R. China.,Artificial Cell Engineering Technology Research Center, Tianjin, P.R. China
| | - Lei Xu
- Department of Critical Care Medicine, Tianjin Third Central Hospital, Tianjin, P.R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, P.R. China.,Key Laboratory of Artificial Cell, Tianjin Third Central Hospital, Tianjin, P.R. China.,Artificial Cell Engineering Technology Research Center, Tianjin, P.R. China
| | - Zhiqiang Luo
- Department of Heart Centre, Tianjin Third Central Hospital, Tianjin, P.R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, P.R. China.,Key Laboratory of Artificial Cell, Tianjin Third Central Hospital, Tianjin, P.R. China.,Artificial Cell Engineering Technology Research Center, Tianjin, P.R. China
| | - Dawei Duan
- Department of Heart Centre, Tianjin Third Central Hospital, Tianjin, P.R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, P.R. China.,Key Laboratory of Artificial Cell, Tianjin Third Central Hospital, Tianjin, P.R. China.,Artificial Cell Engineering Technology Research Center, Tianjin, P.R. China
| | - Peng Wu
- Department of Heart Centre, Tianjin Third Central Hospital, Tianjin, P.R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, P.R. China.,Key Laboratory of Artificial Cell, Tianjin Third Central Hospital, Tianjin, P.R. China.,Artificial Cell Engineering Technology Research Center, Tianjin, P.R. China
| | - Lei Huang
- Department of Heart Centre, Tianjin Third Central Hospital, Tianjin, P.R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, P.R. China.,Key Laboratory of Artificial Cell, Tianjin Third Central Hospital, Tianjin, P.R. China.,Artificial Cell Engineering Technology Research Center, Tianjin, P.R. China
| | - Wenqing Gao
- Department of Heart Centre, Tianjin Third Central Hospital, Tianjin, P.R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, P.R. China.,Key Laboratory of Artificial Cell, Tianjin Third Central Hospital, Tianjin, P.R. China.,Artificial Cell Engineering Technology Research Center, Tianjin, P.R. China
| | - Qunxing Ma
- Department of Heart Centre, Tianjin Third Central Hospital, Tianjin, P.R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, P.R. China.,Key Laboratory of Artificial Cell, Tianjin Third Central Hospital, Tianjin, P.R. China.,Artificial Cell Engineering Technology Research Center, Tianjin, P.R. China
| | - Meng Ning
- Department of Heart Centre, Tianjin Third Central Hospital, Tianjin, P.R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, P.R. China.,Key Laboratory of Artificial Cell, Tianjin Third Central Hospital, Tianjin, P.R. China.,Artificial Cell Engineering Technology Research Center, Tianjin, P.R. China
| | - Tong Li
- Department of Heart Centre, Tianjin Third Central Hospital, Tianjin, P.R. China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Tianjin, P.R. China.,Key Laboratory of Artificial Cell, Tianjin Third Central Hospital, Tianjin, P.R. China.,Artificial Cell Engineering Technology Research Center, Tianjin, P.R. China
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Medar SS, Peek GJ, Rastogi D. Extracorporeal and advanced therapies for progressive refractory near-fatal acute severe asthma in children. Pediatr Pulmonol 2020; 55:1311-1319. [PMID: 32227683 PMCID: PMC9840523 DOI: 10.1002/ppul.24751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/18/2020] [Accepted: 03/18/2020] [Indexed: 01/17/2023]
Abstract
Asthma is the most common chronic illness and is one of the most common medical emergencies in children. Progressive refractory near-fatal asthma requiring intubation and mechanical ventilation can lead to death. Extracorporeal membrane oxygenation (ECMO) can provide adequate gas exchange during acute respiratory failure although data on outcomes in children requiring ECMO support for status asthmaticus is sparse with one study reporting survival rates of nearly 85% with asthma being one of the best outcome subsets for patients with refractory respiratory failure requiring ECMO support. We describe the current literature on the use of ECMO and other advanced extracorporeal therapies available for children with acute severe asthma. We also review other advanced invasive and noninvasive therapies in acute severe asthma both before and while on ECMO support.
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Affiliation(s)
- Shivanand S Medar
- Division of Pediatric Critical Care Medicine, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Giles J Peek
- Department of Pediatric Cardiothoracic Surgery, Shand's Children's Hospital, University of Florida, Gainsville, Florida
| | - Deepa Rastogi
- Division of Pulmonary and Sleep Medicine, Children's National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC
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Deng L, Xia Q, Chi C, Hu G. Awake veno-arterial extracorporeal membrane oxygenation in patients with perioperative period acute heart failure in cardiac surgery. J Thorac Dis 2020; 12:2179-2187. [PMID: 32642123 PMCID: PMC7330313 DOI: 10.21037/jtd.2020.04.38] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is an effective extracorporeal life support technology that has been applied to treat cardiorespiratory failure patients. Some medical centers have started using ECMO on awake, non-intubated, spontaneously breathing patients, as this strategy offers several benefits over mechanical ventilation. However, most awake-ECMO methods focus on venovenous ECMO, and few cases of awake veno-arterial ECMO (V-A ECMO) have been reported, especially in perioperative acute heart failure. Therefore, our study aimed to examine awake—V-A ECMO cases that were not given continuous sedation or invasive mechanical ventilation (IMV) during perioperative heart failure. Method In total, 40 ECMO patients from December 2013 to November 2019 were divided into 2 groups (the awake-ECMO group and the asleep-ECMO group) according to the ventilation use. The demographics, patient outcomes, and ECMO parameters were collected and retrospectively analyzed. Results We identified 12 cases of awake ECMO without continuous ventilation, and 28 cases of simultaneous IMV and ECMO (asleep ECMO). Awake-ECMO patients showed fewer complications and better outcomes compared to ventilation patients. All patients in the awake group were successfully weaned off ECMO, while only 5 (18%) patients were weaned off ECMO in the asleep group. Furthermore, 9 (75%) patients survived until discharge in the awake group vs. 3 (11%) in the asleep group; 3 patients died of septic shock after weaning in the awake group, while 25 patients died of septic shock, hemodynamic disorder, bleeding, cerebral hemorrhage, etc., in the asleep group. These complications, including bleeding, pneumonia, hemolysis, and abdominal distension, etc., occurred less frequently in the asleep group compared to the awake group (P<0.05). Conclusions Awake V-A ECMO is an effective, feasible, and safe strategy in patients with perioperatively acute heart failure and can be applied as a bridge to cardiac function recovery or transplantation.
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Affiliation(s)
- Li Deng
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Qingping Xia
- Department of Medical Research Center, Mudanjiang Medical University, Mudanjiang 157011, China
| | - Chao Chi
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
| | - Guang Hu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, China
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Schulz O, Wiesner O, Welte T, Bollmann BA, Suhling H, Hoeper MM, Busch M. Enoximone in status asthmaticus. ERJ Open Res 2020; 6:00367-2019. [PMID: 32280667 PMCID: PMC7132035 DOI: 10.1183/23120541.00367-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/18/2020] [Indexed: 12/26/2022] Open
Abstract
Bronchial asthma is a chronic disease affecting >300 million people worldwide [1]. The most severe disease manifestation is status asthmaticus, which can be unresponsive to medical therapy. Patients with severe status asthmaticus who require intubation and mechanical ventilation have mortality rates of up to 20% [2]. Airflow obstruction is often so severe that adequate decarboxylation and protective ventilation are not feasible, and extracorporeal membrane oxygenation (ECMO) support is nowadays an established treatment option as a bridge to recovery [3, 4]. In a patient with severe status asthmaticus, enoximone, a phosphodiesterase-3 inhibitor, caused immediate bronchodilationhttp://bit.ly/38UYpUn
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Affiliation(s)
- Oscar Schulz
- Dept of Respiratory Medicine and German Centre for Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - Olaf Wiesner
- Dept of Respiratory Medicine and German Centre for Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - Tobias Welte
- Dept of Respiratory Medicine and German Centre for Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - Benjamin-Alexander Bollmann
- Dept of Respiratory Medicine and German Centre for Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - Hendrik Suhling
- Dept of Respiratory Medicine and German Centre for Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - Marius M Hoeper
- Dept of Respiratory Medicine and German Centre for Lung Research (DZL/BREATH), Hannover Medical School, Hannover, Germany
| | - Markus Busch
- Dept of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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Long B, Lentz S, Koyfman A, Gottlieb M. Evaluation and management of the critically ill adult asthmatic in the emergency department setting. Am J Emerg Med 2020; 44:441-451. [PMID: 32222313 DOI: 10.1016/j.ajem.2020.03.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/08/2020] [Accepted: 03/16/2020] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Asthma is a common reason for presentation to the Emergency Department and is associated with significant morbidity and mortality. While patients may have a relatively benign course, there is a subset of patients who present in a critical state and require emergent management. OBJECTIVE This narrative review provides evidence-based recommendations for the assessment and management of patients with severe asthma. DISCUSSION It is important to consider a broad differential diagnosis for the cause and potential mimics of asthma exacerbation. Once the diagnosis is determined, the majority of the assessment is based upon the clinical examination. First line therapies for severe exacerbations include inhaled short-acting beta agonists, inhaled anticholinergics, intravenous steroids, and magnesium. Additional therapies for refractory cases include parenteral epinephrine or terbutaline, helium‑oxygen mixture, and consideration of ketamine. Intravenous fluids should be administered, as many of these patients are dehydrated and at risk for hypotension if they receive positive pressure ventilatory support. Noninvasive positive pressure ventilation may prevent the need for endotracheal intubation. If mechanical ventilation is required, it is important to avoid breath stacking by setting a low respiratory rate and allowing permissive hypercapnia. Patients with severe asthma exacerbations will require intensive care unit admission. CONCLUSIONS This review provides evidence-based recommendations for the assessment and management of severe asthma with a focus on the emergency clinician.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, VT, United States
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, United States
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Staudinger T. Update on extracorporeal carbon dioxide removal: a comprehensive review on principles, indications, efficiency, and complications. Perfusion 2020; 35:492-508. [PMID: 32156179 DOI: 10.1177/0267659120906048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
TECHNOLOGY Extracorporeal carbon dioxide removal means the removal of carbon dioxide from the blood across a gas exchange membrane without substantially improving oxygenation. Carbon dioxide removal is possible with substantially less extracorporeal blood flow than needed for oxygenation. Techniques for extracorporeal carbon dioxide removal include (1) pumpless arterio-venous circuits, (2) low-flow venovenous circuits based on the technology of continuous renal replacement therapy, and (3) venovenous circuits based on extracorporeal membrane oxygenation technology. INDICATIONS Extracorporeal carbon dioxide removal has been shown to enable more protective ventilation in acute respiratory distress syndrome patients, even beyond the so-called "protective" level. Although experimental data suggest a benefit on ventilator induced lung injury, no hard clinical evidence with respect to improved outcome exists. In addition, extracorporeal carbon dioxide removal is a tool to avoid intubation and mechanical ventilation in patients with acute exacerbated chronic obstructive pulmonary disease failing non-invasive ventilation. This concept has been shown to be effective in 56-90% of patients. Extracorporeal carbon dioxide removal has also been used in ventilated patients with hypercapnic respiratory failure to correct acidosis, unload respiratory muscle burden, and facilitate weaning. In patients suffering from terminal fibrosis awaiting lung transplantation, extracorporeal carbon dioxide removal is able to correct acidosis and enable spontaneous breathing during bridging. Keeping these patients awake, ambulatory, and breathing spontaneously is associated with favorable outcome. COMPLICATIONS Complications of extracorporeal carbon dioxide removal are mostly associated with vascular access and deranged hemostasis leading to bleeding. Although the spectrum of complications may differ, no technology offers advantages with respect to rate and severity of complications. So called "high-extraction systems" working with higher blood flows and larger membranes may be more effective with respect to clinical goals.
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Affiliation(s)
- Thomas Staudinger
- Department of Medicine I, Intensive Care Unit, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
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41
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Medar SS, Derespina KR, Jakobleff WA, Ushay MH, Peek GJ. A winter to remember! Extracorporeal membrane oxygenation for life-threatening asthma in children: A case series and review of literature. Pediatr Pulmonol 2020; 55:E1-E4. [PMID: 31860773 DOI: 10.1002/ppul.24616] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 12/12/2019] [Indexed: 12/17/2022]
Abstract
Progressive refractory near-fatal asthma requiring intubation and mechanical ventilation can lead to death. Data on outcomes in children requiring extracorporeal membrane oxygenation (ECMO) support for status asthmaticus is sparse. We describe our experience of three patients in the winter of 2018 to 2019 successfully rescued with ECMO. We also report our novel use of extubation while still being on ECMO support. Awareness and use of ECMO in refractory asthma can help lower the mortality for this very common disease in children. We also review the current literature on the use of ECMO and other extracorporeal therapies in asthma.
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Affiliation(s)
- Shivanand S Medar
- Division of Pediatric Critical Care Medicine, Children's Hospital at Montefiore & Albert Einstein College of Medicine, Bronx, New York.,Division of Pediatric Cardiology, Children's Hospital at Montefiore & Albert Einstein College of Medicine, Bronx, New York
| | - Kim R Derespina
- Division of Pediatric Critical Care Medicine, Children's Hospital at Montefiore & Albert Einstein College of Medicine, Bronx, New York
| | - William A Jakobleff
- Department of Cardiothoracic Surgery, Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, New York
| | - Michael H Ushay
- Division of Pediatric Critical Care Medicine, Children's Hospital at Montefiore & Albert Einstein College of Medicine, Bronx, New York
| | - Giles J Peek
- Department of Pediatric Cardiothoracic Surgery, Shand's Children's Hospital, University of Florida, Gainsville, Florida
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Ock HS, Kang LH, Yeo HJ, Yoon SH, Cho WH, Jeon DS, Kim YS, Lee SE. Utilization of extracorporeal membrane oxygenation for refractory status asthmaticus during pregnancy: A case report. ALLERGY ASTHMA & RESPIRATORY DISEASE 2020. [DOI: 10.4168/aard.2020.8.2.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Hye Sung Ock
- Department of Pulmonology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Lae Hyung Kang
- Department of Pulmonology, Good Moonhwa Hospital, Busan, Korea
| | - Hye Ju Yeo
- Department of Pulmonology and Allergy, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seong Hoon Yoon
- Department of Pulmonology and Allergy, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Woo Hyun Cho
- Department of Pulmonology and Allergy, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Doo Soo Jeon
- Department of Pulmonology and Allergy, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yun Seong Kim
- Department of Pulmonology and Allergy, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seung Eun Lee
- Department of Pulmonology and Allergy, Pusan National University Yangsan Hospital, Yangsan, Korea
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Acute Severe Asthma in Adolescent and Adult Patients: Current Perspectives on Assessment and Management. J Clin Med 2019; 8:jcm8091283. [PMID: 31443563 PMCID: PMC6780340 DOI: 10.3390/jcm8091283] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 08/09/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
Asthma is a chronic airway inflammatory disease that is associated with variable expiratory flow, variable respiratory symptoms, and exacerbations which sometimes require hospitalization or may be fatal. It is not only patients with severe and poorly controlled asthma that are at risk for an acute severe exacerbation, but this has also been observed in patients with otherwise mild or moderate asthma. This review discusses current aspects on the pathogenesis and pathophysiology of acute severe asthma exacerbations and provides the current perspectives on the management of acute severe asthma attacks in the emergency department and the intensive care unit.
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44
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Vutipongsatorn K, Fujitake E, Singh S. Extracorporeal membrane oxygenation in life-threatening asthma unresponsive to mechanical ventilation: a comparison of patient demographics and outcomes between a large London-based intensive care unit and an international registry. Clin Med (Lond) 2019. [DOI: 10.7861/clinmedicine.19-3-s19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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45
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Vutipongsatorn K, Fujitake E, Singh S. Extracorporeal membrane oxygenation in life-threatening asthma unresponsive to mechanical ventilation: a comparison of patient demographics and outcomes between a large London-based intensive care unit and an international registry. Clin Med (Lond) 2019. [DOI: 10.7861/clinmedicine.19-3s-s19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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46
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Hill GED, Traudt RJ, Durham LA, Pagel PS, Tawil JN. Successful Treatment of Refractory Status Asthmaticus Accompanied by Right Ventricular Dysfunction Using a Protek Duo Tandem Heart Device. J Cardiothorac Vasc Anesth 2019; 33:3085-3089. [PMID: 31076305 DOI: 10.1053/j.jvca.2019.03.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/12/2019] [Accepted: 03/14/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Graham E D Hill
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Ryan J Traudt
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Lucian A Durham
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
| | - Justin N Tawil
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
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47
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Chavasse R, Scott S. The Differences in Acute Management of Asthma in Adults and Children. Front Pediatr 2019; 7:64. [PMID: 30931286 PMCID: PMC6424020 DOI: 10.3389/fped.2019.00064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/18/2019] [Indexed: 11/13/2022] Open
Abstract
Acute asthma or wheeze is a common presentation to emergency services for both adults and children. Although there are phenotypic differences between asthma syndromes, the management of acute symptoms follow similar lines. This article looks at the similarities and differences in approaches for children and adults. Some of these may be age dependent, such as the physiological parameters used to define the severity of the attack or the use of age appropriate inhaler devices. Other differences may reflect the availability of evidence. In other areas there is conflicting evidence between adult and pediatric studies such as a temporary increase in dose of inhaled corticosteroids during an acute attack. Overall there are more similarities than differences.
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Affiliation(s)
- Richard Chavasse
- Consultant Respiratory Paediatrician, St George's University Hospitals NHS Foundation Trust, St George's University of London, London, United Kingdom
| | - Stephen Scott
- Consultant in Respiratory Medicine, The Countess of Chester Hospital NHS Foundation Trust, Cheshire, United Kingdom
- Chester Medical School, The University of Chester, Chester, United Kingdom
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48
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Chacko CJ, Goyal S, Yusuff H. Awake extracorporeal membrane oxygenation patients expanding the horizons. J Thorac Dis 2018; 10:S2215-S2216. [PMID: 30123565 DOI: 10.21037/jtd.2018.06.28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Cyril J Chacko
- University Hospitals of Leicester, ECMO program, Glenfield Hospital, Leicester, UK
| | - Shradha Goyal
- University Hospitals of Leicester, ECMO program, Glenfield Hospital, Leicester, UK
| | - Hakeem Yusuff
- University Hospitals of Leicester, ECMO program, Glenfield Hospital, Leicester, UK
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