Respiratory failure oxygen therapy: Difference between revisions

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==Overview==
==Overview==
A trial of non-invasive ventilation (NIV) may be carried out in order to achieve hypoxemic correction. NIV is advantageous in carrying less infection and mortality rates than traditional mechanical ventilation. ECMO is a cardiopulmonary support machine that is useful in cases of acute severe respiratory failure.  
A trial of non-invasive ventilation (NIV) may be carried out in order to achieve [[Hypoxemia|hypoxemic]] correction. NIV is advantageous in carrying less [[infection]] and [[Mortality rate|mortality]] rates than traditional [[mechanical ventilation]]. [[Extracorporeal membrane oxygenation|ECMO]] is a cardiopulmonary support machine that is useful in cases of acute severe respiratory failure.  


==Oxygen therapy==
==Oxygen therapy==
*The aim of oxygen therapy is to correct hypoxia.<ref name="pmid28860265">{{cite journal |vauthors=Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S |title=Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure |journal=Eur. Respir. J. |volume=50 |issue=2 |pages= |date=August 2017 |pmid=28860265 |pmc=5593345 |doi=10.1183/13993003.02426-2016 |url=}}</ref>
*The aim of oxygen therapy is to correct [[hypoxia]].<ref name="pmid28860265">{{cite journal |vauthors=Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S |title=Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure |journal=Eur. Respir. J. |volume=50 |issue=2 |pages= |date=August 2017 |pmid=28860265 |pmc=5593345 |doi=10.1183/13993003.02426-2016 |url=}}</ref>
*These therapies may include:
*These therapies may include:
**Non-invasive ventilatory support  
**Non-invasive ventilatory support  
**Extracorporeal membrane oxygenation
**[[Extracorporeal membrane oxygenation]]


===Non-invasive ventilatory support (NIV)===
===Non-invasive ventilatory support (NIV)===
*Non-invasive ventilatory support (NIV) uses positive pressure ventilation delivered through a face or nasal mask or nasal prongs as a non-invasive way of delivering oxygen. (Different pressure types will be discussed in the mechanical ventilation section of this chapter).<ref name="pmid11208659">{{cite journal |vauthors= |title=International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure |journal=Am. J. Respir. Crit. Care Med. |volume=163 |issue=1 |pages=283–91 |date=January 2001 |pmid=11208659 |doi=10.1164/ajrccm.163.1.ats1000 |url=}}</ref><ref name="pmid7697242">{{cite journal |vauthors=Ferguson GT, Gilmartin M |title=CO2 rebreathing during BiPAP ventilatory assistance |journal=Am. J. Respir. Crit. Care Med. |volume=151 |issue=4 |pages=1126–35 |date=April 1995 |pmid=7697242 |doi=10.1164/ajrccm.151.4.7697242 |url=}}</ref><ref name="pmid12907562">{{cite journal |vauthors=Liesching T, Kwok H, Hill NS |title=Acute applications of noninvasive positive pressure ventilation |journal=Chest |volume=124 |issue=2 |pages=699–713 |date=August 2003 |pmid=12907562 |doi= |url=}}</ref><ref name="pmid8045145">{{cite journal |vauthors=Soo Hoo GW, Santiago S, Williams AJ |title=Nasal mechanical ventilation for hypercapnic respiratory failure in chronic obstructive pulmonary disease: determinants of success and failure |journal=Crit. Care Med. |volume=22 |issue=8 |pages=1253–61 |date=August 1994 |pmid=8045145 |doi= |url=}}</ref>
*Non-invasive ventilatory support (NIV) uses [[positive pressure ventilation]] delivered through a face or nasal mask or nasal prongs as a non-invasive way of delivering oxygen. (Different pressure types will be discussed in the [[mechanical ventilation]] section of this chapter).<ref name="pmid11208659">{{cite journal |vauthors= |title=International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure |journal=Am. J. Respir. Crit. Care Med. |volume=163 |issue=1 |pages=283–91 |date=January 2001 |pmid=11208659 |doi=10.1164/ajrccm.163.1.ats1000 |url=}}</ref><ref name="pmid7697242">{{cite journal |vauthors=Ferguson GT, Gilmartin M |title=CO2 rebreathing during BiPAP ventilatory assistance |journal=Am. J. Respir. Crit. Care Med. |volume=151 |issue=4 |pages=1126–35 |date=April 1995 |pmid=7697242 |doi=10.1164/ajrccm.151.4.7697242 |url=}}</ref><ref name="pmid12907562">{{cite journal |vauthors=Liesching T, Kwok H, Hill NS |title=Acute applications of noninvasive positive pressure ventilation |journal=Chest |volume=124 |issue=2 |pages=699–713 |date=August 2003 |pmid=12907562 |doi= |url=}}</ref><ref name="pmid8045145">{{cite journal |vauthors=Soo Hoo GW, Santiago S, Williams AJ |title=Nasal mechanical ventilation for hypercapnic respiratory failure in chronic obstructive pulmonary disease: determinants of success and failure |journal=Crit. Care Med. |volume=22 |issue=8 |pages=1253–61 |date=August 1994 |pmid=8045145 |doi= |url=}}</ref>
*Non-invasive ventilatory support (NIV) is indicated for:
*Non-invasive ventilatory support (NIV) is indicated for:
**Acute hypoxemic respiratory failure
**Acute hypoxemic respiratory failure
**Chronic obstructive pulmonary disease (COPD) complicated by hypercapnic acidosis  
**[[Chronic obstructive pulmonary disease]] ([[Chronic obstructive pulmonary disease|COPD]]) complicated by hypercapnic [[acidosis]]
*Use of (NIV) is contraindicated in cases of need of emergent intubation, such as:  
*Use of (NIV) is contraindicated in cases of need of emergent intubation, such as:  
**Myocardial arrest
**[[Myocardial infarction|Myocardial arrest]]
**Respiratory arrest
**[[Respiratory arrest]]
**Inability to preserve a patent airways
**Inability to preserve a patent airways
**Severely altered consciousness
**Severely altered consciousness
**Life threatening organ failiure of nonpulmonary origin
**Life threatening [[organ failure]] of nonpulmonary origin
**Abnormalities of facial structure for any reason
**Abnormalities of facial structure for any reason
**High risk of aspiration
**High risk of [[aspiration]]
**Expected long term treatment with mechanical ventilation
**Expected long term treatment with [[mechanical ventilation]]
**Recent esophageal surgery with anastomoses
**Recent esophageal surgery with anastomoses


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*Success or failure of NIV therapy is established within an initial observation period of 8 hours.<ref name="pmid17019559">{{cite journal |vauthors=Demoule A, Girou E, Richard JC, Taille S, Brochard L |title=Benefits and risks of success or failure of noninvasive ventilation |journal=Intensive Care Med |volume=32 |issue=11 |pages=1756–65 |date=November 2006 |pmid=17019559 |doi=10.1007/s00134-006-0324-1 |url=}}</ref>
*Success or failure of NIV therapy is established within an initial observation period of 8 hours.<ref name="pmid17019559">{{cite journal |vauthors=Demoule A, Girou E, Richard JC, Taille S, Brochard L |title=Benefits and risks of success or failure of noninvasive ventilation |journal=Intensive Care Med |volume=32 |issue=11 |pages=1756–65 |date=November 2006 |pmid=17019559 |doi=10.1007/s00134-006-0324-1 |url=}}</ref>
**During this time adjustments should be made, whilst looking for signs of destabilization.
**During this time adjustments should be made, whilst looking for signs of destabilization.
*An improvement in arterial carbon dioxide tension (PaCO2) and pH within 1.5 - 2 hours is indicative of successful NIV.
*An improvement in arterial [[carbon dioxide]] tension (PaCO2) and pH within 1.5 - 2 hours is indicative of successful NIV.
*Indications of failed NIV include:
*Indications of failed NIV include:
**A lack of improvement in arterial carbon dioxide tension (PaCO2) and pH within 1.5 - 2 hours
**A lack of improvement in arterial [[carbon dioxide]] tension (PaCO2) and pH within 1.5 - 2 hours
**Encephalopathy
**[[Encephalopathy]]
**Agitation
**[[Agitation]]
**Unclearable secretions
**Unclearable secretions
**Intolerable mask interface
**Intolerable mask interface
**Decreased oxygen saturation  
**Decreased [[oxygen saturation]]
**Hemodynamic instability  
**[[Shock|Hemodynamic instability]]
*Successful selection of patients with indications for NIV by physicians is poor and therefore, a third of patients that receive a trial of NIV fail.
*Successful selection of patients with indications for NIV by physicians is poor and therefore, a third of patients that receive a trial of NIV fail.
*The use of sedatives and analgesics, for purposes of comfort and anxiety is not recommended as studies have demonstrated an increase in NIV failure rates with pretreatment of these agents.
*The use of [[Sedative|sedatives]] and [[Analgesic|analgesics]], for purposes of comfort and anxiety is not recommended as studies have demonstrated an increase in NIV failure rates with pretreatment of these agents.


====Weaning====
====Weaning====
Weaning is carried out through progressively decreasing positive pressure settings, whilst permitting the patient longer durations without ventilation.
[[Weaning]] is carried out through progressively decreasing positive pressure settings, whilst permitting the patient longer durations without ventilation.


====Advantages of NIV====
====Advantages of NIV====
*NIV has lower mortality rates (23%) in comparison to traditional mechanical ventilation (39%).<ref name="pmid9407237">{{cite journal |vauthors=Guérin C, Girard R, Chemorin C, De Varax R, Fournier G |title=Facial mask noninvasive mechanical ventilation reduces the incidence of nosocomial pneumonia. A prospective epidemiological survey from a single ICU |journal=Intensive Care Med |volume=23 |issue=10 |pages=1024–32 |date=October 1997 |pmid=9407237 |doi= |url=}}</ref><ref name="pmid15972113">{{cite journal |vauthors=Hess DR |title=Noninvasive positive-pressure ventilation and ventilator-associated pneumonia |journal=Respir Care |volume=50 |issue=7 |pages=924–9; discussion 929–31 |date=July 2005 |pmid=15972113 |doi= |url=}}</ref>
*NIV has lower [[Mortality rate|mortality rates]] (23%) in comparison to traditional [[mechanical ventilation]] (39%).<ref name="pmid9407237">{{cite journal |vauthors=Guérin C, Girard R, Chemorin C, De Varax R, Fournier G |title=Facial mask noninvasive mechanical ventilation reduces the incidence of nosocomial pneumonia. A prospective epidemiological survey from a single ICU |journal=Intensive Care Med |volume=23 |issue=10 |pages=1024–32 |date=October 1997 |pmid=9407237 |doi= |url=}}</ref><ref name="pmid15972113">{{cite journal |vauthors=Hess DR |title=Noninvasive positive-pressure ventilation and ventilator-associated pneumonia |journal=Respir Care |volume=50 |issue=7 |pages=924–9; discussion 929–31 |date=July 2005 |pmid=15972113 |doi= |url=}}</ref>
*NIV therapy carries less risk of nosocomial infection transmission such as ventilator - associated pneumonias, sinusitis and line sepsis.
*NIV therapy carries less risk of [[nosocomial infection]] transmission such as ventilator - associated [[Pneumonia|pneumonias]], [[sinusitis]] and line sepsis.
*NIV facilitates a decreased need for invasive mechanical ventilation.
*NIV facilitates a decreased need for invasive [[mechanical ventilation]].


===Extracorporeal membrane oxygenation (ECMO)===
===Extracorporeal membrane oxygenation (ECMO)===
*Extracorporeal membrane oxygenation (ECMO) is a mechanical cardiopulmonary support, which can run temporarily in place of the heart and lungs.
*[[Extracorporeal membrane oxygenation]] ([[Extracorporeal membrane oxygenation|ECMO]]) is a mechanical cardiopulmonary support, which can run temporarily in place of the heart and lungs.
*ECMO is most often applied intraoperatively to facilitate cardiac surgery.
*[[Extracorporeal membrane oxygenation|ECMO]] is most often applied intraoperatively to facilitate cardiac surgery.


[[Image:Ecmo schema-1-.jpg|thumb|center|500px|Source:commons.wikimedia.org, shows ECMO circuit by Jürgen Schaub. de:User:Mr.Flintstone - transfrered from de:Datei:Ecmo schema.jpgOwn work, CC BY-SA 2.0 de, https://commons.wikimedia.org/w/index.php?curid=8756034]]
[[Image:Ecmo schema-1-.jpg|thumb|center|500px|Source:commons.wikimedia.org, shows ECMO circuit by Jürgen Schaub. de:User:Mr.Flintstone - transfrered from de:Datei:Ecmo schema.jpgOwn work, CC BY-SA 2.0 de, https://commons.wikimedia.org/w/index.php?curid=8756034]]


====ECMO procedure====
====ECMO procedure====
*During ECMO blood is extracted from the vascular system and circulated invitro to a mechanical pump outside the body.<ref name="pmid10598597">{{cite journal |vauthors=Ullrich R, Lorber C, Röder G, Urak G, Faryniak B, Sladen RN, Germann P |title=Controlled airway pressure therapy, nitric oxide inhalation, prone position, and extracorporeal membrane oxygenation (ECMO) as components of an integrated approach to ARDS |journal=Anesthesiology |volume=91 |issue=6 |pages=1577–86 |date=December 1999 |pmid=10598597 |doi= |url=}}</ref><ref name="pmid9556124">{{cite journal |vauthors=Rich PB, Awad SS, Kolla S, Annich G, Schreiner RJ, Hirschl RB, Bartlett RH |title=An approach to the treatment of severe adult respiratory failure |journal=J Crit Care |volume=13 |issue=1 |pages=26–36 |date=March 1998 |pmid=9556124 |doi= |url=}}</ref><ref name="pmid9351722">{{cite journal |vauthors=Kolla S, Awad SS, Rich PB, Schreiner RJ, Hirschl RB, Bartlett RH |title=Extracorporeal life support for 100 adult patients with severe respiratory failure |journal=Ann. Surg. |volume=226 |issue=4 |pages=544–64; discussion 565–6 |date=October 1997 |pmid=9351722 |pmc=1191077 |doi= |url=}}</ref><ref name="pmid19822628">{{cite journal |vauthors=Davies A, Jones D, Bailey M, Beca J, Bellomo R, Blackwell N, Forrest P, Gattas D, Granger E, Herkes R, Jackson A, McGuinness S, Nair P, Pellegrino V, Pettilä V, Plunkett B, Pye R, Torzillo P, Webb S, Wilson M, Ziegenfuss M |title=Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome |journal=JAMA |volume=302 |issue=17 |pages=1888–95 |date=November 2009 |pmid=19822628 |doi=10.1001/jama.2009.1535 |url=}}</ref><ref name="pmid19768656">{{cite journal |vauthors=Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL |title=Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database |journal=Intensive Care Med |volume=35 |issue=12 |pages=2105–14 |date=December 2009 |pmid=19768656 |doi=10.1007/s00134-009-1661-7 |url=}}</ref>
*During [[Extracorporeal membrane oxygenation|ECMO]] blood is extracted from the vascular system and circulated invitro to a mechanical pump outside the body.<ref name="pmid10598597">{{cite journal |vauthors=Ullrich R, Lorber C, Röder G, Urak G, Faryniak B, Sladen RN, Germann P |title=Controlled airway pressure therapy, nitric oxide inhalation, prone position, and extracorporeal membrane oxygenation (ECMO) as components of an integrated approach to ARDS |journal=Anesthesiology |volume=91 |issue=6 |pages=1577–86 |date=December 1999 |pmid=10598597 |doi= |url=}}</ref><ref name="pmid9556124">{{cite journal |vauthors=Rich PB, Awad SS, Kolla S, Annich G, Schreiner RJ, Hirschl RB, Bartlett RH |title=An approach to the treatment of severe adult respiratory failure |journal=J Crit Care |volume=13 |issue=1 |pages=26–36 |date=March 1998 |pmid=9556124 |doi= |url=}}</ref><ref name="pmid9351722">{{cite journal |vauthors=Kolla S, Awad SS, Rich PB, Schreiner RJ, Hirschl RB, Bartlett RH |title=Extracorporeal life support for 100 adult patients with severe respiratory failure |journal=Ann. Surg. |volume=226 |issue=4 |pages=544–64; discussion 565–6 |date=October 1997 |pmid=9351722 |pmc=1191077 |doi= |url=}}</ref><ref name="pmid19822628">{{cite journal |vauthors=Davies A, Jones D, Bailey M, Beca J, Bellomo R, Blackwell N, Forrest P, Gattas D, Granger E, Herkes R, Jackson A, McGuinness S, Nair P, Pellegrino V, Pettilä V, Plunkett B, Pye R, Torzillo P, Webb S, Wilson M, Ziegenfuss M |title=Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome |journal=JAMA |volume=302 |issue=17 |pages=1888–95 |date=November 2009 |pmid=19822628 |doi=10.1001/jama.2009.1535 |url=}}</ref><ref name="pmid19768656">{{cite journal |vauthors=Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL |title=Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database |journal=Intensive Care Med |volume=35 |issue=12 |pages=2105–14 |date=December 2009 |pmid=19768656 |doi=10.1007/s00134-009-1661-7 |url=}}</ref>
*During this period where the blood is outside the body, the blood passes through an oxygenator and a heat exchanger.  
*During this period where the blood is outside the body, the blood passes through an [[oxygenator]] and a [[heat exchanger]].  
*The blood is fully saturated with oxygen and waste gases, such as carbon dioxide are removed.
*The blood is fully saturated with [[oxygen]] and waste gases, such as [[carbon dioxide]] are removed.
*The rate of oxygenation depends on the flow rate through the ECMO circuit, whilst C02 exchange is dependent upon the rate of countercurrent flow through the oxygenator.  
*The rate of oxygenation depends on the flow rate through the [[Extracorporeal membrane oxygenation|ECMO]] circuit, whilst C02 exchange is dependent upon the rate of countercurrent flow through the [[oxygenator]].  
*The blood is then returned to the body.  
*The blood is then returned to the body.  


====Indications====
====Indications====
*ECMO may be indicated in two types of severe acute respiratory failure:<ref name="pmid15383787">{{cite journal |vauthors=Hemmila MR, Rowe SA, Boules TN, Miskulin J, McGillicuddy JW, Schuerer DJ, Haft JW, Swaniker F, Arbabi S, Hirschl RB, Bartlett RH |title=Extracorporeal life support for severe acute respiratory distress syndrome in adults |journal=Ann. Surg. |volume=240 |issue=4 |pages=595–605; discussion 605–7 |date=October 2004 |pmid=15383787 |pmc=1356461 |doi= |url=}}</ref><ref name="pmid9315812">{{cite journal |vauthors=Peek GJ, Moore HM, Moore N, Sosnowski AW, Firmin RK |title=Extracorporeal membrane oxygenation for adult respiratory failure |journal=Chest |volume=112 |issue=3 |pages=759–64 |date=September 1997 |pmid=9315812 |doi= |url=}}</ref><ref name="pmid9310799">{{cite journal |vauthors=Lewandowski K, Rossaint R, Pappert D, Gerlach H, Slama KJ, Weidemann H, Frey DJ, Hoffmann O, Keske U, Falke KJ |title=High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation |journal=Intensive Care Med |volume=23 |issue=8 |pages=819–35 |date=August 1997 |pmid=9310799 |doi= |url=}}</ref>
*[[Extracorporeal membrane oxygenation|ECMO]] may be indicated in two types of severe acute respiratory failure:<ref name="pmid15383787">{{cite journal |vauthors=Hemmila MR, Rowe SA, Boules TN, Miskulin J, McGillicuddy JW, Schuerer DJ, Haft JW, Swaniker F, Arbabi S, Hirschl RB, Bartlett RH |title=Extracorporeal life support for severe acute respiratory distress syndrome in adults |journal=Ann. Surg. |volume=240 |issue=4 |pages=595–605; discussion 605–7 |date=October 2004 |pmid=15383787 |pmc=1356461 |doi= |url=}}</ref><ref name="pmid9315812">{{cite journal |vauthors=Peek GJ, Moore HM, Moore N, Sosnowski AW, Firmin RK |title=Extracorporeal membrane oxygenation for adult respiratory failure |journal=Chest |volume=112 |issue=3 |pages=759–64 |date=September 1997 |pmid=9315812 |doi= |url=}}</ref><ref name="pmid9310799">{{cite journal |vauthors=Lewandowski K, Rossaint R, Pappert D, Gerlach H, Slama KJ, Weidemann H, Frey DJ, Hoffmann O, Keske U, Falke KJ |title=High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation |journal=Intensive Care Med |volume=23 |issue=8 |pages=819–35 |date=August 1997 |pmid=9310799 |doi= |url=}}</ref>
**Type I hypoxemic respiratory failure where the PaO2/FiO2 (a ratio of arterial oxygen tension to fraction of inspired oxygen) is less than 100mmHg, whilst the tidal volume, inspiratory to expiratory (I:E) ratio, and positive end-expiratory pressure are all optimal.  
**Type I hypoxemic respiratory failure where the PaO2/FiO2 (a ratio of arterial oxygen tension to fraction of inspired oxygen) is less than 100mmHg, whilst the [[tidal volume]], inspiratory to expiratory (I:E) ratio, and [[positive end-expiratory pressure]] are all optimal.  
**Type II hypercapnic respiratory failure with an arterial pH less than 7.20.
**Type II hypercapnic respiratory failure with an arterial pH less than 7.20.
*Survival rates in patients with acute severe respiratory failure who receive ECMO compared to those that don't receive ECMo are 71% and 50% respectively.  
*Survival rates in patients with acute severe respiratory failure who receive [[Extracorporeal membrane oxygenation|ECMO]] compared to those that don't receive [[Extracorporeal membrane oxygenation|ECMO]] are 71% and 50% respectively.  


====Types of ECMO====
====Types of ECMO====
*VV (Venovenous) ECMO:<ref name="pmid9315812">{{cite journal |vauthors=Peek GJ, Moore HM, Moore N, Sosnowski AW, Firmin RK |title=Extracorporeal membrane oxygenation for adult respiratory failure |journal=Chest |volume=112 |issue=3 |pages=759–64 |date=September 1997 |pmid=9315812 |doi= |url=}}</ref><ref name="pmid9310799">{{cite journal |vauthors=Lewandowski K, Rossaint R, Pappert D, Gerlach H, Slama KJ, Weidemann H, Frey DJ, Hoffmann O, Keske U, Falke KJ |title=High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation |journal=Intensive Care Med |volume=23 |issue=8 |pages=819–35 |date=August 1997 |pmid=9310799 |doi= |url=}}</ref>
*VV (Venovenous) [[Extracorporeal membrane oxygenation|ECMO]]:<ref name="pmid9315812">{{cite journal |vauthors=Peek GJ, Moore HM, Moore N, Sosnowski AW, Firmin RK |title=Extracorporeal membrane oxygenation for adult respiratory failure |journal=Chest |volume=112 |issue=3 |pages=759–64 |date=September 1997 |pmid=9315812 |doi= |url=}}</ref><ref name="pmid9310799">{{cite journal |vauthors=Lewandowski K, Rossaint R, Pappert D, Gerlach H, Slama KJ, Weidemann H, Frey DJ, Hoffmann O, Keske U, Falke KJ |title=High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation |journal=Intensive Care Med |volume=23 |issue=8 |pages=819–35 |date=August 1997 |pmid=9310799 |doi= |url=}}</ref>
**Blood is drawn from the vena cava or right atrium and returned to the right atrium.
**Blood is drawn from the [[Vena cavae|vena cava]] or [[right atrium]] and returned to the [[right atrium]].
*VA (Venoarterial) ECMO:
*VA (Venoarterial) [[Extracorporeal membrane oxygenation|ECMO]]:
**Blood is drawn from the right atrium and returned to the arterial system, bypassing the heart and lungs.
**Blood is drawn from the [[right atrium]] and returned to the arterial system, bypassing the heart and lungs.


====Contraindications to ECMO====
====Contraindications to ECMO====
*Absolute contraindications:<ref name="pmid22926653">{{cite journal |vauthors=Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, Brochard L, Brower R, Esteban A, Gattinoni L, Rhodes A, Slutsky AS, Vincent JL, Rubenfeld GD, Thompson BT, Ranieri VM |title=The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material |journal=Intensive Care Med |volume=38 |issue=10 |pages=1573–82 |date=October 2012 |pmid=22926653 |doi=10.1007/s00134-012-2682-1 |url=}}</ref>
*Absolute contraindications:<ref name="pmid22926653">{{cite journal |vauthors=Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, Brochard L, Brower R, Esteban A, Gattinoni L, Rhodes A, Slutsky AS, Vincent JL, Rubenfeld GD, Thompson BT, Ranieri VM |title=The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material |journal=Intensive Care Med |volume=38 |issue=10 |pages=1573–82 |date=October 2012 |pmid=22926653 |doi=10.1007/s00134-012-2682-1 |url=}}</ref>
**Severe neurologic impairment
**Severe neurologic impairment
**Advance stage malignancy
**Advanced stage [[Cancer|malignancy]]
*Relative contraindications:
*Relative contraindications:
**Primary condition has a poor prognosis
**Primary condition has a poor prognosis
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====Weaning and complications of ECMO====
====Weaning and complications of ECMO====
*Patients with respiratory failure may be weaned off ECMO, when the following improvements are noted:<ref name="pmid27456703">{{cite journal |vauthors=Braune S, Sieweke A, Brettner F, Staudinger T, Joannidis M, Verbrugge S, Frings D, Nierhaus A, Wegscheider K, Kluge S |title=The feasibility and safety of extracorporeal carbon dioxide removal to avoid intubation in patients with COPD unresponsive to noninvasive ventilation for acute hypercapnic respiratory failure (ECLAIR study): multicentre case-control study |journal=Intensive Care Med |volume=42 |issue=9 |pages=1437–44 |date=September 2016 |pmid=27456703 |doi=10.1007/s00134-016-4452-y |url=}}</ref><ref name="pmid26893318">{{cite journal |vauthors=Rush B, Wiskar K, Berger L, Griesdale D |title=Trends in Extracorporeal Membrane Oxygenation for the Treatment of Acute Respiratory Distress Syndrome in the United States |journal=J Intensive Care Med |volume=32 |issue=9 |pages=535–539 |date=October 2017 |pmid=26893318 |doi=10.1177/0885066616631956 |url=}}</ref>
*Patients with respiratory failure may be weaned off [[Extracorporeal membrane oxygenation|ECMO]], when the following improvements are noted:<ref name="pmid27456703">{{cite journal |vauthors=Braune S, Sieweke A, Brettner F, Staudinger T, Joannidis M, Verbrugge S, Frings D, Nierhaus A, Wegscheider K, Kluge S |title=The feasibility and safety of extracorporeal carbon dioxide removal to avoid intubation in patients with COPD unresponsive to noninvasive ventilation for acute hypercapnic respiratory failure (ECLAIR study): multicentre case-control study |journal=Intensive Care Med |volume=42 |issue=9 |pages=1437–44 |date=September 2016 |pmid=27456703 |doi=10.1007/s00134-016-4452-y |url=}}</ref><ref name="pmid26893318">{{cite journal |vauthors=Rush B, Wiskar K, Berger L, Griesdale D |title=Trends in Extracorporeal Membrane Oxygenation for the Treatment of Acute Respiratory Distress Syndrome in the United States |journal=J Intensive Care Med |volume=32 |issue=9 |pages=535–539 |date=October 2017 |pmid=26893318 |doi=10.1177/0885066616631956 |url=}}</ref>
**Improvements on chest radiograph in radiographic appearance
**Improvements on [[Chest X-ray|chest radiograph]] 
**Increase in pulmonary compliance
**Increase in [[pulmonary compliance]]
**Increase in arterial oxyhemoglobin saturation  
**Increase in arterial oxyhemoglobin saturation  
*Weaning with VV (Venovenous) ECMO:
*Weaning with VV (Venovenous) [[Extracorporeal membrane oxygenation|ECMO]]:
**Weaning trials are carried out by allowing the blood to continue flowing through the ECMO circuit, however without gas transference.
**Weaning trials are carried out by allowing the blood to continue flowing through the ECMO circuit, however without gas transference.
*Weaning with VA (Venoarterial) ECMO:
*Weaning with VA (Venoarterial) [[Extracorporeal membrane oxygenation|ECMO]]:
**Weaning trials are carried out by temporary clamping of both the drainage and infusion lines, whilst allowing the ECMO circuit to circulate to avoid thromboembolism.
**Weaning trials are carried out by temporary clamping of both the drainage and infusion lines, whilst allowing the [[Extracorporeal membrane oxygenation|ECMO]] circuit to circulate to avoid [[thromboembolism]].
*Complications of ECMO include:
*Complications of [[Extracorporeal membrane oxygenation|ECMO]] include:
**Bleeding
**[[Bleeding]]
**Thromboembolism
**[[Thromboembolism]]




Revision as of 13:47, 12 March 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Overview

A trial of non-invasive ventilation (NIV) may be carried out in order to achieve hypoxemic correction. NIV is advantageous in carrying less infection and mortality rates than traditional mechanical ventilation. ECMO is a cardiopulmonary support machine that is useful in cases of acute severe respiratory failure.

Oxygen therapy

Non-invasive ventilatory support (NIV)

Mask selection

  • Studies have demonstrated that a face mask confers the largest physiological improvement, whilst nasal masks and prongs are tolerated the best.[4][6][5][7]
  • Face masks are preferred in several studies and have the following advantages:
    • Less air leaks compared to volumes lost with nasal masks through the oral cavity
    • Nasal masks increase resistance to air flow and therefore, increase respiratory effort
    • Face masks make it easier to assess aspiration risk in comparison to a nasal mask

Ventilatory modes

Will be discussed in the mechanical ventilation section of this chapter.

Monitoring NIV

  • Success or failure of NIV therapy is established within an initial observation period of 8 hours.[8]
    • During this time adjustments should be made, whilst looking for signs of destabilization.
  • An improvement in arterial carbon dioxide tension (PaCO2) and pH within 1.5 - 2 hours is indicative of successful NIV.
  • Indications of failed NIV include:
  • Successful selection of patients with indications for NIV by physicians is poor and therefore, a third of patients that receive a trial of NIV fail.
  • The use of sedatives and analgesics, for purposes of comfort and anxiety is not recommended as studies have demonstrated an increase in NIV failure rates with pretreatment of these agents.

Weaning

Weaning is carried out through progressively decreasing positive pressure settings, whilst permitting the patient longer durations without ventilation.

Advantages of NIV

Extracorporeal membrane oxygenation (ECMO)

  • Extracorporeal membrane oxygenation (ECMO) is a mechanical cardiopulmonary support, which can run temporarily in place of the heart and lungs.
  • ECMO is most often applied intraoperatively to facilitate cardiac surgery.
Source:commons.wikimedia.org, shows ECMO circuit by Jürgen Schaub. de:User:Mr.Flintstone - transfrered from de:Datei:Ecmo schema.jpgOwn work, CC BY-SA 2.0 de, https://commons.wikimedia.org/w/index.php?curid=8756034

ECMO procedure

  • During ECMO blood is extracted from the vascular system and circulated invitro to a mechanical pump outside the body.[11][12][13][14][15]
  • During this period where the blood is outside the body, the blood passes through an oxygenator and a heat exchanger.
  • The blood is fully saturated with oxygen and waste gases, such as carbon dioxide are removed.
  • The rate of oxygenation depends on the flow rate through the ECMO circuit, whilst C02 exchange is dependent upon the rate of countercurrent flow through the oxygenator.
  • The blood is then returned to the body.

Indications

  • ECMO may be indicated in two types of severe acute respiratory failure:[16][17][18]
    • Type I hypoxemic respiratory failure where the PaO2/FiO2 (a ratio of arterial oxygen tension to fraction of inspired oxygen) is less than 100mmHg, whilst the tidal volume, inspiratory to expiratory (I:E) ratio, and positive end-expiratory pressure are all optimal.
    • Type II hypercapnic respiratory failure with an arterial pH less than 7.20.
  • Survival rates in patients with acute severe respiratory failure who receive ECMO compared to those that don't receive ECMO are 71% and 50% respectively.

Types of ECMO

Contraindications to ECMO

  • Absolute contraindications:[19]
    • Severe neurologic impairment
    • Advanced stage malignancy
  • Relative contraindications:
    • Primary condition has a poor prognosis
    • Severe unremitting bleeding

Weaning and complications of ECMO

  • Patients with respiratory failure may be weaned off ECMO, when the following improvements are noted:[20][21]
  • Weaning with VV (Venovenous) ECMO:
    • Weaning trials are carried out by allowing the blood to continue flowing through the ECMO circuit, however without gas transference.
  • Weaning with VA (Venoarterial) ECMO:
    • Weaning trials are carried out by temporary clamping of both the drainage and infusion lines, whilst allowing the ECMO circuit to circulate to avoid thromboembolism.
  • Complications of ECMO include:


References

  1. ↑ Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P, Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S (August 2017). "Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure". Eur. Respir. J. 50 (2). doi:10.1183/13993003.02426-2016. PMC 5593345. PMID 28860265.
  2. ↑ "International Consensus Conferences in Intensive Care Medicine: noninvasive positive pressure ventilation in acute Respiratory failure". Am. J. Respir. Crit. Care Med. 163 (1): 283–91. January 2001. doi:10.1164/ajrccm.163.1.ats1000. PMID 11208659.
  3. ↑ Ferguson GT, Gilmartin M (April 1995). "CO2 rebreathing during BiPAP ventilatory assistance". Am. J. Respir. Crit. Care Med. 151 (4): 1126–35. doi:10.1164/ajrccm.151.4.7697242. PMID 7697242.
  4. ↑ 4.0 4.1 Liesching T, Kwok H, Hill NS (August 2003). "Acute applications of noninvasive positive pressure ventilation". Chest. 124 (2): 699–713. PMID 12907562.
  5. ↑ 5.0 5.1 Soo Hoo GW, Santiago S, Williams AJ (August 1994). "Nasal mechanical ventilation for hypercapnic respiratory failure in chronic obstructive pulmonary disease: determinants of success and failure". Crit. Care Med. 22 (8): 1253–61. PMID 8045145.
  6. ↑ Holland AE, Denehy L, Buchan CA, Wilson JW (January 2007). "Efficacy of a heated passover humidifier during noninvasive ventilation: a bench study". Respir Care. 52 (1): 38–44. PMID 17194316.
  7. ↑ Antón A, Güell R, Gómez J, Serrano J, Castellano A, Carrasco JL, Sanchis J (March 2000). "Predicting the result of noninvasive ventilation in severe acute exacerbations of patients with chronic airflow limitation". Chest. 117 (3): 828–33. PMID 10713013.
  8. ↑ Demoule A, Girou E, Richard JC, Taille S, Brochard L (November 2006). "Benefits and risks of success or failure of noninvasive ventilation". Intensive Care Med. 32 (11): 1756–65. doi:10.1007/s00134-006-0324-1. PMID 17019559.
  9. ↑ Guérin C, Girard R, Chemorin C, De Varax R, Fournier G (October 1997). "Facial mask noninvasive mechanical ventilation reduces the incidence of nosocomial pneumonia. A prospective epidemiological survey from a single ICU". Intensive Care Med. 23 (10): 1024–32. PMID 9407237.
  10. ↑ Hess DR (July 2005). "Noninvasive positive-pressure ventilation and ventilator-associated pneumonia". Respir Care. 50 (7): 924–9, discussion 929–31. PMID 15972113.
  11. ↑ Ullrich R, Lorber C, Röder G, Urak G, Faryniak B, Sladen RN, Germann P (December 1999). "Controlled airway pressure therapy, nitric oxide inhalation, prone position, and extracorporeal membrane oxygenation (ECMO) as components of an integrated approach to ARDS". Anesthesiology. 91 (6): 1577–86. PMID 10598597.
  12. ↑ Rich PB, Awad SS, Kolla S, Annich G, Schreiner RJ, Hirschl RB, Bartlett RH (March 1998). "An approach to the treatment of severe adult respiratory failure". J Crit Care. 13 (1): 26–36. PMID 9556124.
  13. ↑ Kolla S, Awad SS, Rich PB, Schreiner RJ, Hirschl RB, Bartlett RH (October 1997). "Extracorporeal life support for 100 adult patients with severe respiratory failure". Ann. Surg. 226 (4): 544–64, discussion 565–6. PMC 1191077. PMID 9351722.
  14. ↑ Davies A, Jones D, Bailey M, Beca J, Bellomo R, Blackwell N, Forrest P, Gattas D, Granger E, Herkes R, Jackson A, McGuinness S, Nair P, Pellegrino V, Pettilä V, Plunkett B, Pye R, Torzillo P, Webb S, Wilson M, Ziegenfuss M (November 2009). "Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome". JAMA. 302 (17): 1888–95. doi:10.1001/jama.2009.1535. PMID 19822628.
  15. ↑ Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL (December 2009). "Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database". Intensive Care Med. 35 (12): 2105–14. doi:10.1007/s00134-009-1661-7. PMID 19768656.
  16. ↑ Hemmila MR, Rowe SA, Boules TN, Miskulin J, McGillicuddy JW, Schuerer DJ, Haft JW, Swaniker F, Arbabi S, Hirschl RB, Bartlett RH (October 2004). "Extracorporeal life support for severe acute respiratory distress syndrome in adults". Ann. Surg. 240 (4): 595–605, discussion 605–7. PMC 1356461. PMID 15383787.
  17. ↑ 17.0 17.1 Peek GJ, Moore HM, Moore N, Sosnowski AW, Firmin RK (September 1997). "Extracorporeal membrane oxygenation for adult respiratory failure". Chest. 112 (3): 759–64. PMID 9315812.
  18. ↑ 18.0 18.1 Lewandowski K, Rossaint R, Pappert D, Gerlach H, Slama KJ, Weidemann H, Frey DJ, Hoffmann O, Keske U, Falke KJ (August 1997). "High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation". Intensive Care Med. 23 (8): 819–35. PMID 9310799.
  19. ↑ Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, Brochard L, Brower R, Esteban A, Gattinoni L, Rhodes A, Slutsky AS, Vincent JL, Rubenfeld GD, Thompson BT, Ranieri VM (October 2012). "The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material". Intensive Care Med. 38 (10): 1573–82. doi:10.1007/s00134-012-2682-1. PMID 22926653.
  20. ↑ Braune S, Sieweke A, Brettner F, Staudinger T, Joannidis M, Verbrugge S, Frings D, Nierhaus A, Wegscheider K, Kluge S (September 2016). "The feasibility and safety of extracorporeal carbon dioxide removal to avoid intubation in patients with COPD unresponsive to noninvasive ventilation for acute hypercapnic respiratory failure (ECLAIR study): multicentre case-control study". Intensive Care Med. 42 (9): 1437–44. doi:10.1007/s00134-016-4452-y. PMID 27456703.
  21. ↑ Rush B, Wiskar K, Berger L, Griesdale D (October 2017). "Trends in Extracorporeal Membrane Oxygenation for the Treatment of Acute Respiratory Distress Syndrome in the United States". J Intensive Care Med. 32 (9): 535–539. doi:10.1177/0885066616631956. PMID 26893318.

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