RESUMEN
Historically, patients on extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome have received ventilatory "lung rest" with conventional or high-frequency oscillating ventilators. We present a series of adults treated with high-frequency percussive ventilation (HFPV) to enhance recovery and recruitment during ECMO. Adult respiratory patients, treated between January 2009 and December 2012 were cared for with a combination of standard ECMO practices and a protocol of recruitment strategies, including HFPV. Data are reported as mean ± standard error of the mean, percentage, or median. Comparisons are made by χ for categorical variables and by t-test and Mann-Whitney test for continuous variables. Significance is noted at the 95% confidence level (p < 0.05). There were 39 HFPV patients. They were 39.9 ± 2.2 years of age and had 3.0 ± 0.37 days of mechanical ventilation before the initiation of ECMO. Their pre-ECMO PaO2 to FiO2 ratio (PF ratio) was 52.3 ± 3.0 and their pCO2 was 50.22 ± 2.4. HFPV patients required a mean of 143.1 ± 17.6 hours and a median of 106 hours (range 45.75-350.25) of ECMO support and had a 62% survival to discharge. The post-ECMO PF ratio in the HFPV cohort was 301.8 ± 16.7. A protocolized practice of active recruitment that includes HFPV is associated with reduced duration of ECMO support in adults with respiratory failure.
Asunto(s)
Oxigenación por Membrana Extracorpórea/métodos , Ventilación de Alta Frecuencia/métodos , Síndrome de Dificultad Respiratoria/terapia , Adolescente , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Síndrome de Dificultad Respiratoria/complicaciones , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Adulto JovenRESUMEN
BACKGROUND: Patients with severe H1N1 pneumonia created a sudden demand for extracorporeal membrane oxygenation (ECMO) capacity. In a single referral center, the established procedures, protocols, and staff of the Level I trauma service were adapted to help manage this nontrauma critical care crisis. METHODS: When airway pressure release ventilation and high-frequency oscillator ventilation failed, we used standard ECMO circuits and the VDR-4 critical care ventilator. We cannulated patients percutaneously in the intensive care unit and transported them on ECMO. Trauma service resources included a mobile surgical transport team, direct to OR resuscitations, massive transfusion protocols, trauma performance improvement processes, trauma resuscitation nurses, in-house attending doctors, and experienced staff familiar with protocol-driven care. RESULTS: During an 84-day period, 15 patients with severe H1N1 pneumonia were treated with ECMO. All patients were referred; 10 were transported on ECMO. Patients were aged 34.4 ± 4.1 years (6-58 years); 47% were male, and they had been ventilated 3.5 ± 0.8 days. Pre-ECMO PaO2/FIO2 ratios were 62.3 ± 6.1; ECMO duration was 9.4 ± 1.3 days for survivors; and post-ECMO PaO2/FIO2 ratio was 295.0 ± 35.1. Recovery occurred in 67% and 60% survived to discharge. No patient died of lung failure. Surviving patients were discharged at their neurologic baseline. CONCLUSION: H1N1 created a severe public health challenge for referral centers with ECMO capability. The resources of our trauma service were adapted to this nontrauma critical care crisis without disruption of other hospital services. These H1N1 patients treated with ECMO had a 67% recovery rate and a 60% survival rate. All survivors were discharged to home. LEVEL OF EVIDENCE: Therapeutic/epidemiologic study, level V.