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[临床决策]:ECMO治疗重症ARDS选项1:推荐开始vv-ECMO
2018年09月22日 临床话题, 模拟诊室 暂无评论

CLINICAL DECISIONS

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome

Michael Y. Mi, Michael A. Matthay, and Alan H. Morris

N Engl J Med 2018; 379:884-887

DOI: 10.1056/NEJMclde1804601

Recommend Initiation of Venovenous ECMO

Michael A. Matthay, M.D.

This 36-year-old man has very severe ARDS caused by influenza pneumonia. His Pao2 is only 50 mm Hg, with an Fio2 of 1.0 and PEEP of 15 cm of water, and his arterial oxygen saturation is 80 to 82%. He has moderately severe acidosis, with a pH of 7.22 and a Paco2 of 62 mm Hg. He meets the criteria for the use of rescue therapies because he has severe hypoxemia and acidosis despite treatment with lung-protective low tidal volume ventilation, neuromuscular blockade with deep sedation, and prone positioning. What additional interventions could we offer him?

Inhaled nitric oxide can improve oxygenation, although sustained benefit is difficult to achieve and there is no evidence that it results in a reduction in the risk of death. Another option would be to reduce his tidal volume to 4 to 5 ml per kilogram of predicted body weight, but he already has a Paco2 of 62 mm Hg, probably because of a high dead-space fraction.1 In addition, lowering the tidal volume will most likely worsen his respiratory acidosis. He could be treated with recruitment maneuvers, but one recent trial raises concerns about this approach,2 and in the case of Mr. Jackson in particular, it may not be advisable since his plateau airway pressure is already 30 cm of water. Increasing PEEP higher than the current 15 cm of water may also raise the plateau airway pressure above 30 cm of water, which could cause lung overdistention that could aggravate his lung injury.3 Another approach would be diuresis, but his systemic hypotension (blood pressure of 92/58 mm Hg) would most likely limit this option. Renal-replacement therapy could potentially reduce pulmonary edema and correct acidosis. However, his acidosis is primarily respiratory in origin, and he does not appear to have marked volume overload. In addition, evidence for the possible value of renal-replacement therapy derives mainly from one single-site study.4 Glucocorticoids could be tried, but they may cause harm in a patient with influenza pneumonia.5

Thus, I favor venovenous ECMO. The patient meets standard criteria for ECMO, including those in the ECMO to Rescue Lung Injury in Severe ARDS (EOLIA) trial, the results of which were published recently in the Journal.6 This relatively young patient does not meet exclusion criteria for ECMO (cardiac failure, advanced chronic lung disease, cancer, severe neurologic injury, or major coexisting conditions), and he has single-organ failure. Although the randomized EOLIA trial — in which early ECMO was compared with conventional mechanical ventilation with crossover to ECMO for refractory hypoxemia — did not show a significantly lower rate of the primary end point (mortality at 60 days) in the ECMO group than in the conventional-treatment group, there was a nonsignificant indication of potential benefit (a rate of 35% in the ECMO group vs. 46% in the control group, P=0.09). Furthermore, the EOLIA trial may have been underpowered, especially since the trial was stopped after enrollment of only 75% of the planned 331 patients. In terms of secondary outcomes, the ECMO-treated patients had significantly more days alive and free of prone positioning and renal-replacement therapy than patients in the conventional-treatment group. In addition, a benefit in favor of ECMO was observed for the prespecified secondary outcome of crossover to ECMO (28% crossover rate) or death. With respect to adverse events, there was a numerically higher incidence of stroke in the conventional-treatment group, and there was no significant difference between the two groups in the incidence of hemorrhagic stroke. On balance, this patient is an excellent candidate for ECMO if it can be delivered in a medical center that is experienced with this therapy.

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