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The Potential Role of Extracorporeal Membrane Oxygenation

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The Potential Role of Extracorporeal Membrane Oxygenation Opinion Preparing for the Most Critically Ill Patients With COVID-19 VIEWPOINT The Potential Role of Extracorporeal Membrane Oxygenation Graeme MacLaren, The novel coronavirus has now infected tens of thou- greater. To address this, prompt mobilization of exist- MSc sands of people in China and has spread rapidly around ing registries and clinical research groups should help fa- Cardiothoracic the globe.1 The World Health Organization (WHO) cilitate the systematic collection of data. For example, Intensive Care Unit, has declared the disease, coronavirus disease 2019 the Extracorporeal Life Support Organization (ELSO) National University Health System, (COVID-19), a Public Health Emergency of International Registry is being adapted to acquire new information Singapore. Concern and released interim guidelines on patient about COVID-19 and prospective observational studies management.2 Early reports that emerged from Wuhan, are under way. Dale Fisher, MBBS the epicenter of the outbreak, demonstrated that the ECMO does not provide direct support for organs Division of Infectious clinical manifestations of infection were fever, cough, other than the lungs or heart beyond increasing Diseases, University Medicine Cluster, and dyspnea, with radiological evidence of viral systemic oxygen delivery and mitigating ventilator- National University pneumonia.3,4 Approximately 15% to 30% of these pa- induced lung injury. A substantial proportion of criti- Health Systems, tients developed acute respiratory distress syndrome cally ill patients with COVID-19 appear to have devel- Singapore; and 3 Department of (ARDS). The WHO interim guidelines made general rec- oped cardiac arrhythmias or shock, but it is unknown Medicine, Yong Loo Lin ommendations for treatment of ARDS in this setting, in- how many have or will develop refractory multiorgan School of Medicine, cluding that consideration be given to referring pa- failure, for which ECMO may be of more limited use. To National University of tients with refractory hypoxemia to expert centers postulate about the potential benefit of ECMO in this Singapore, Singapore. capable of providing extracorporeal membrane oxygen- infection, more data on the mechanism of death and 2 Daniel Brodie, MD ation (ECMO). disease are required. The virus may cause death Division of Pulmonary, ECMO is a form of modified cardiopulmonary by- through progressive hypoxic respiratory failure, septic Allergy and Critical Care pass in which venous blood is removed from the body shock, refractory multiorgan failure, or by precipitating Medicine, Columbia and pumped through an artificial membrane lung in pa- exacerbation of comorbid diseases such as ischemic University College of 5 Physicians and tients who have refractory respiratory or cardiac failure. heart disease or cardiac failure, but the relative propor- Surgeons/New Oxygen is added, carbon dioxide is removed, and blood tions of these diseases in large cohorts of patients with York-Presbyterian is returned to the patient, either via another vein to pro- COVID-19 infection are unknown. Hospital, New York; and Center for Acute vide respiratory support or a major artery to provide cir- The global spread of COVID-19, although the num- Respiratory Failure, culatory support. ECMO is a resource-intensive, highly ber of cases outside of China remains small, will likely New York-Presbyterian specialized, and expensive form of life support with the occur via many dispersed epicenters where local trans- Hospital, New York. mission has become established. If these epicenters occur in sophisticated ECMO is not a therapy to be rushed health care systems with preexisting to the frontline when all resources ECMO programs, this will provide vital information about the utility of are stretched in a pandemic. ECMO and help anticipate global de- mand. Should the initial experience be potential for significant complications, in particular hem- encouraging, it is likely that non-ECMO centers will orrhage and nosocomial infection. Recent evidence sug- refer early to ECMO centers in anticipation of impend- gests that use of ECMO in the most severe cases of ARDS ing clinical deterioration. This will disproportionately is associated with reduced mortality.6 There is some evi- affect hospitals with ECMO programs, even when dence that outcomes from ECMO are better in higher- ECMO is not required. volume centers.7 Furthermore, with the apparent contagiousness The role of ECMO in the management of COVID-19 of this virus and the relatively high numbers of is unclear at this point. It has been used in some pa- patients who require intensive care, this may prove tients with COVID-19 in China but detailed information very resource-consumptive. Countries will need to is unavailable.3 ECMO may have a role in the manage- pay specific attention to the considerable investment Corresponding ment of some patients with COVID-19 who have refrac- needed to provide ECMO during this outbreak. Judg- Author: Graeme tory hypoxemic respiratory failure.6 However, much ment will be needed to decide when ECMO may be MacLaren, MSc, about the virus is unknown, including the natural his- worthwhile and when it may not, understanding that Cardiothoracic Intensive Care Unit, tory, incidence of late complications, viral persistence, the risk-to-benefit ratio of performing ECMO in these National University or the prognoses in different subsets of patients. This un- circumstances is dynamic and dependent on many Health System, 5 Lower certainty might be compared to the emergence of in- factors. If the mechanism of death in COVID-19 ulti- Kent Ridge Rd, fluenza A(H1N1) in 2009, when it was initially unclear mately includes a substantial number of patients with Singapore 119074 8 ([email protected]. what the role of ECMO should be. However, the de- septic shock or refractory multiorgan failure, then the au). gree of uncertainty surrounding COVID-19 is much shift away from ECMO is likely to occur earlier because jama.com (Reprinted) JAMA April 7, 2020 Volume 323, Number 13 1245 © 2020 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 Opinion Viewpoint the most severely ill patients in this cohort would be less likely to provide ECMO to be overwhelmed with critically ill patients unless benefit. The higher the all-cause mortality, the less relevant interhospital transfers are centrally coordinated. ECMO becomes. With the WHO recommendation for ECMO in place and the tro- Regardless, ECMO is clearly a finite resource. In a large out- pism of the COVID-19 virus for severe respiratory illness, the num- break, additional limitations to providing ECMO may include a lack ber of cases in which ECMO is used may increase over the course of of ECMO consoles or disposable equipment, suitably trained staff, this outbreak. However, there may come a tipping point. Should the or isolation rooms with the requisite infrastructure. Many materials case volume in any given region increase beyond the ability to pro- necessary to make ECMO circuitry are manufactured in China and vide routine care, any earlier increase in ECMO use may give way, it is conceivable that the outbreak may disrupt supply chains. with utilization later decreasing in proportion to the overwhelming A number of different models of ECMO service provision demands on the system as a whole. exist worldwide, ranging from a relative lack of regulation and Support with ECMO is for the most critically ill patients in centralization—with many hospitals having ECMO capability but regions with the extensive resources required to provide this often with very low case volumes (eg, in the US or Japan)—through therapy. ECMO is not a therapy to be rushed to the frontline when to regional or national coordination of ECMO referral centers with all resources are stretched in a pandemic. In less well-resourced dedicated interhospital retrieval teams (eg, New Zealand, Australia, countries, many more lives will be saved by ensuring oxygen and Singapore, Qatar, the United Kingdom, or Sweden). In response to pulse oximetry are widely available. Mitigation efforts to slow the influenza A(H1N1) in 2009, some countries such as Italy adopted outbreak are critical so that health care systems are not over- the latter model and it is possible that COVID-19 could be ad- whelmed and all patients receive the correct management, dressed similarly. The advantages of such an approach include stan- whether simply confirmation of the diagnosis and appropriate dardization of indications, management, data collection, and quarantine, oxygen therapy alone, mechanical ventilation or, for containment.5,7 The disadvantage is the potential for hospitals that those most likely to benefit, ECMO. ARTICLE INFORMATION www.who.int/publications-detail/clinical- 6. Goligher EC, Tomlinson G, Hajage D, et al. Published Online: February 19, 2020. management-of-severe-acute-respiratory- Extracorporeal membrane oxygenation for severe doi:10.1001/jama.2020.2342 infection-when-novel-coronavirus-(ncov)- acute respiratory distress syndrome and posterior infection-is-suspected probability of mortality benefit in a post hoc Conflict of Interest Disclosures: Dr Brodie bayesian analysis of a randomized clinical trial. JAMA. reported receiving grants from Alung Technologies, 3. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel 2018;320(21):2251-2259. doi:10.1001/jama.2018. serving on the medical advisory board for Alung 14276 Technologies, Xenios, Breethe, Baxter, and coronavirus-infected pneumonia in Wuhan, China. Hemovent. No other disclosures were reported. JAMA. Published online February 7, 2020. doi:10. 7. Barbaro RP, Odetola FO, Kidwell KM, et al. 1001/jama.2020.1585 Association of hospital-level volume of REFERENCES 4. Chen N, Zhou M, Dong X, et al. Epidemiological extracorporeal membrane oxygenation cases and and clinical characteristics of 99 cases of 2019 mortality. Analysis of the extracorporeal life support 1. Paules CI, Marston HD, Fauci AS. Coronavirus organization registry. Am J Respir Crit Care Med. infections—more than just the common cold. JAMA. novel coronavirus pneumonia in Wuhan, China: a descriptive study.
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