Article, Pulmonology

Use of extracorporeal membrane oxygenation in severe traumatic lung injury with respiratory failure

a b s t r a c t

Objectives: The use of extracorporeal membrane oxygenation in managing acute respiratory distress syn- drome had been accepted. Severe lung injury with respiratory failure is often encountered in trauma patients. We report our experience with the use of ECMO in severe traumatic lung injury.

Methods: Patients with severe traumatic lung injury that met the following criteria were candidates for ECMO:

(1) severe hypoxemia, PaO2/fraction of inspired oxygen (1.0) less than 60, and positive end-expiratory pressure greater than 10 cm H2O in spite of vigorous ventilation strategy; (2) irreversible CO2 retention with unstable he- modynamics; and (3) an initial arterial PaO2/fraction of inspired oxygen (1.0) less than 60, where the pulmonary condition and hemodynamics rapidly deteriorated despite vigorous mechanical ventilation strategy.

Results: Over 60 months, a total of 19 patients with severe traumatic lung injury who received ECMO manage- ment were retrospectively reviewed. The median age was 38 years (25-58 years), the median injury severity score was 29 (25-34), the median admission Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 25 (21-36), and the median blood transfusion volume was 5500 mL (3500-13 000). There were 9 venovenous and 10 venoarterial types. The survival rate was 68.4% (13/19). The survivors were younger (30 vs 53 years; 21-39 vs 48-63).

There were 6 mortalities (3 pneumonia, 2 coagulopathy, and 1 Cardiac rupture with cardiac tamponade). There were 5 of 19 patients with pre-ECMO traumatic Brain hemorrhage (3 survived and 2 mortalities). A total of 16 patients received heparinization with 5 mortalities.

Conclusions: The use of ECMO may offer an additional Treatment modality in severe traumatic lung injury with respiratory failure that is unresponsive to optimal conventional ventilator support. Timely ECMO intervention is of value.

(C) 2015

Introduction

Severe trauma is one of the leading causes of death in young adults [1,2], and approximately 50% of cases are associated with chest injury in multiple trauma [3]. Most lung injury patients with mild to moderate

? Conflicts of interest: The authors declare no conflicts of interest related to this study.

?? Author contributions: Wu SC did the study conception and design, initial draft of man-

uscript, interpretation, and manuscript drafting and revision. Chen WT participated in the study design and conception; Lin HH performed the procedure of extracorporeal membrane oxygenation. Fu CY, Wang YC, Lo HC, Cheng HT, and Tzeng CW did the data collection.

? Guarantor of the article: Shih-Chi Wu, MD.

* Corresponding author at: Trauma and Emergency Center, China Medical university hospital, No. 2 Yuh-Der Road, Taichung, Taiwan 404, R.O.C. Tel.: +886 4 22052121×5043; fax: +886 4 22334706.

E-mail addresses: [email protected] (S.-C. Wu), [email protected] (W.T.-L. Chen), [email protected] (H.-H. Lin), [email protected] (C.-Y. Fu), [email protected] (Y.-C. Wang), [email protected] (H.-C. Lo), [email protected] (H.-T. Cheng), [email protected] (C.-W. Tzeng).

respiratory failure respond well to noninvasive respiratory support. How- ever, a small number of lung injury patients may develop severe respirato- ry failure and progress from hypoxia with systemic inflammatory response syndrome to acute lung injury or Acute respiratory distress syndrome . Intubation and mechanical ventilation in these patients may be- come mandatory to correct hypoxia and hypercapnia. Generally, manage- ment with a lower tidal volume and higher Positive end-expiratory pressure is recommended in such respiratory distress [4-6]. How- ever, there were patients who progressed to lung failure even with vigor- ous ventilation support. The hospital survival rates of patients with severe lung dysfunction have ranged from 26% to 58% [7-10]. In cases when most treatment options, including invasive ventilation, have failed, the use of ex- tracorporeal membrane oxygenation (ECMO) may be used as a temporary replacement for the injured lungs; it serves to reduce Ventilator settings and prevent further barotrauma [11,12]; provide adequate ventilation, ox- ygenation, and improvement of hypercapnia; and provide the effect of “lung rest” and buy time for recovery of lungs [13].

http://dx.doi.org/10.1016/j.ajem.2015.02.007

0735-6757/(C) 2015

The use of ECMO in severe neonatal respiratory failure has been pre- viously reported [14]. Recently, there were reports regarding the use of ECMO as a therapeutic option for ARDS in adults [11,12,15].

Massive blood loss and massive transfusion often resulted in “coag- ulopathy” in Multiple trauma patients, which limited the use of ECMO in severe traumatic lung injury because of systemic heparinization. Thus, the use of ECMO in patients with severe traumatic lung injury remains controversial due to the risk of Bleeding complications [16,17]. Howev- er, Arlt et al [18] reported the use of ECMO in 10 patients with severe trauma and hemorrhagic shock with a 60% survival rate, indicating that there might be a role for ECMO in severe traumatic lung injury pa- tients with coagulopathy.

We were interested in the role of ECMO in severe traumatic lung inju- ry and performed this retrospective study. We report our experience with the use of ECMO in severe traumatic lung injury and respiratory failure.

Materials and methods

We retrospectively reviewed the charts of patients who had severe traumatic lung injury that was refractory to conventional therapy and received extracorporeal lung support (ECMO) and were admitted to our intensive care unit (ICU) at the Trauma and Emergency Center from January 2008 to January 2014.

The data abstracted from the chart contained no identifying patient information. Those abstracting data were trained in the use of standard- ized data collection forms and were periodically monitored for accuracy. An assessment of interrater reliability was performed.

Institutional review board approval was not required for this type of retrospective research in our institution.

Inclusion criteria for ECMO in severe traumatic lung injury

Patients with traumatic lung injury who received conventional man- agement initially were considered candidates for ECMO when they met one of the following criteria: