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Extracorporeal Membrane Oxygenation during Respiratory Pandemics: Past, Present, and Future
The role of extracorporeal membrane oxygenation (ECMO) in the management of severe acute respiratory failure, including acute respiratory distress syndrome, has become better defined in recent years in light of emerging high-quality evidence and technological advances. Use of ECMO has consequently increased throughout many parts of the world. The coronavirus disease (COVID-19) pandemic, however, has highlighted deficiencies in organizational capacity, research capability, knowledge sharing, and resource use.
Although governments, medical societies, hospital systems, and clinicians were collectively unprepared for the scope of this pandemic, the use of ECMO, a highly resource-intensive and specialized form of life support, presented specific logistical and ethical challenges. As the pandemic has evolved, there has been greater collaboration in the use of ECMO across centers and regions, together with more robust data reporting through international registries and observational studies.
Nevertheless, centralization of ECMO capacity is lacking in many regions of the world, and equitable use of ECMO resources remains uneven. There are no widely available mechanisms to conduct large-scale, rigorous clinical trials in real time. In this critical care review, we outline lessons learned during COVID-19 and prior respiratory pandemics in which ECMO was used, and we describe how we might apply these lessons going forward, both during the ongoing COVID-19 pandemic and in the future.
Target Audience
Pulmonologists, critical care specialists, translational researchers, and clinicians
Learning Objectives
At the conclusion of this activity, learners should be able to:
- Evaluate the effectiveness of extracorporeal membrane oxygenation (ECMO) in the management of COVID-19–associated acute respiratory distress syndrome at different timepoints during the pandemic.
- Develop strategies to handle a potential increase in ECMO candidates during a respiratory pandemic.
- Identify different research strategies and study designs that may be leveraged to evaluate ECMO efficacy in real-time during a respiratory pandemic.
Accreditation Statement
The American Thoracic Society is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Disclosure Declaration
The current practice of the American Journal of Respiratory and Critical Care Medicine (AJRCCM) is to publish high quality, peer-reviewed and evidence-based original research, Concise Clinical Reviews, Guidelines and Consensus Statements. Articles published in AJRCCM include evidence-based summaries of optimal practice (Concise Clinical Reviews), evidence-based guidelines, workshop summaries and original contributions that will influence clinical practice. The publication of these articles by itself is only one piece of a multi-step process for the translation of evidence-based improvements in care to clinical practice. Articles selected for CME credit are designed to be the next step in the process of translating clinically relevant, evidence-based recommendations into clinical practice. This will be accomplished through a series of questions specifically designed by the author(s) to test that readers have the tools needed to translate recommendations for diagnostic and therapeutic clinical care into clinical practice. Members of the AJRCCM editorial board will review these questions and assess the quality of the questions based on:
- Clarity,
- Educational content, and
- The quality of the evidence supporting the response to the question. Posttest questions will assess if practitioners have understood the most important recommendations available for the diagnosis and treatment of pulmonary diseases, critical illness, and sleep disorders and are able to implement them into clinical practice.
Article Authorship Disclosures (as submitted to the ATS prior to article publication date)
Daniel Brodie, M.D. (Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, NY, USA) reported grants from ALung Technologies; consulting fees from Cellenkos, Medtronic, Abiomed, Xenios, and Inspira; and being chair of the International ECMO Network (ECMONet) and President-Elect of the Extracorporeal Life Support Organization (ELSO).
Darryl Abrams, M.D. (Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, NY, USA) reported being an at-large member of the ELSO steering committee, an unpaid position.
Graeme MacLaren, M.B.B.S., M.Sc. (National University Health System, Singapore) reported serving on the board of directors of ELSO.
Crystal E. Brown, M.D., M.A. (Harborview Medical Center, University of Washington, Seattle, WA, USA) reported grants from the National Institute of Minority Health and Health Disparities.
Laura Evans, M.D., M.Sc. (University of Washington, Seattle, WA, USA) reported no relevant financial relationships.
Ryan P. Barbaro, M.D., M.S. (University of Michigan, Ann Arbor, MI, USA) reported grants from the National Institutes of Health (R01 HL153519, R01 HD015434, and K12 HL138039); and being registry chair of ELSO.
Carolyn S. Calfee, M.D. (University of California San Francisco, San Francisco, CA, USA) reported grants or contracts from NIH, Roche/Genentech, Bayer, and Quantum Leap Healthcare Collaborative; and consulting fees from Roche/Genentech, Bayer, Quark Pharmaceuticals, Gen1e Life Sciences, Vasomune, and Janssen.
Catherine L. Hough, M.D., M.Sc. (Oregon Health and Science University, Portland, OR, USA) reported being a member of ECMONet.
Jo-anne Fowles, M.Sc., R.N. (Royal Papworth Hospital NHS Foundation Trust, Division of Surgery, Transplant & Anaesthetics, Cambridge, UK) reported reported being a member of the Euro-ELSO Steering Group and the Intensive Care Society Nurse Advisory Group.
Christian Karagiannidis, M.D. (Kliniken der Stadt Köln, Witten/Herdecke University Hospital, Cologne, Germany) reported grants or contracts from the German Ministry of Research and Education; consulting fees from Maquet, Xenios, and Baxter; and nonfinancial support from Speaker of the German register of ICUs.
Arthur S. Slutsky, M.D. (University of Toronto, Toronto, Ontario, Canada) reported consulting fees from Baxter, Novalung/Xenios, Aperion, Cellenkos, Diffusion Pharmaceuticals, and Statking.
Alain Combes, M.D., Ph.D. (Sorbonne Université, INSERM, UMRS1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France) reported grants or contracts from Maquet and Baxter; consulting fees from Maquet and Baxter; and being a past president of EuroELSO and conference committee chair of ECMONet.
Disclosures of AJRCCM CME Planners
The current practice of the American Journal of Respiratory and Critical Care Medicine (AJRCCM) is to publish high quality, peer-reviewed and evidence-based original research, Concise Clinical Reviews, Guidelines and Consensus Statements. Articles published in AJRCCM include evidence-based summaries of optimal practice (Concise Clinical Reviews), evidence-based guidelines, workshop summaries and original contributions that will influence clinical practice. The publication of these articles by itself is only one piece of a multi-step process for the translation of evidence-based improvements in care to clinical practice. Articles selected for CME credit are designed to be the next step in the process of translating clinically relevant, evidence-based recommendations into clinical practice. This will be accomplished through a series of questions specifically designed by the author(s) to test that readers have the tools needed to translate recommendations for diagnostic and therapeutic clinical care into clinical practice. Members of the AJRCCM editorial board will review these questions and assess the quality of the questions based on (1) clarity, (2) educational content, and (3) the quality of the evidence supporting the response to the question. Posttest questions will assess if practitioners have understood the most important recommendations available for the diagnosis and treatment of pulmonary diseases, critical illness, and sleep disorders and are able to implement them into clinical practice.
Off-Label Usage Disclosure
None
AJRCCM CME Planners
Harold Collard, M.D.
Associate Editor, AJRCCM
Dr. Collard reported that he is on the advisory committee of Bayer, Biogen, Boehringer Ingelheim, Fibrogen, Genentech, Gilead, Intermune, and Promedior; and is a consultant at Five Prime.
Gerard J. Criner, M.D.
Associate Editor, AJRCCM
Dr. Criner reported that he has research awards from Aeris Therapeutics, AstraZeneca, Boehringer Ingelheim, Forest Laboratories, GlaxoSmithKline, Ikaria, Medimmune, Novartis, Pearl, PneumRx, Pulmonx, Respironics, Spectral Diagnostics, and Theratechnologies Inc.; and has received lecture fees from Almirall, AstraZeneca, Boehringer Ingelheim, Celerion, CSA Medical Inc., Johnson & Johnson, and Respivert.
Jadwiga A. Wedzicha, M.D.
Editor-in-Chief, AJRCCM
Dr. Wedzicha reported that she is on the advisory committee of Napp, Pfizer, and Takeda; has research awards from Chiesi, Takeda, and Vifor Pharma; and has received lecture fees from Almirall, Bayer, Boehringer Ingelheim, Novartis, and Takeda.
Instructions to Receive Credit
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- Read the journal article. Keep track of how long it takes you to read it.
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Available Credit
- 1.00 AMA PRA Category 1 Credit(s)™The American Thoracic Society designates this for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
- 1.00 Participation