Spontaneous Breathing during Extracorporeal Membrane Oxygenation in Acute Respiratory Failure
Spontaneous Breathing during Extracorporeal Membrane Oxygenation in Acute Respiratory Failure
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DOI：
10.1097/aln.0000000000001546
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发表时间：
2017-04-01
期刊：
影响因子：
8.8
通讯作者：
Gattinoni, Luciano
中科院分区：
文献类型：
--
作者：
Crotti, Stefania;Bottino, Nicola;Gattinoni, Luciano
背景资料：我们评估了体外膜肺氧合自主呼吸的临床可行性，以及人工肺和自体肺之间的相互作用，患者桥接肺移植或慢性阻塞性肺疾病（COPD）急性加重期或急性呼吸窘迫综合征。方法：共48例患者的临床过程进行了分析。48例患者中的23例入组前瞻性研究（9例桥接至肺移植，6例COPD和8例急性呼吸窘迫综合征）。通过增加呼吸频率和食管压力波动来评估对二氧化碳去除的反应。（“救济”门槛）和（“痛苦”阈值）体外膜氧合气体流量，从基线条件开始。考虑到所有48例患者，100%桥肺移植患者进行了自主呼吸体外膜肺氧合（9/9例拔管）、86%的COPD（5/6例拔管）和27%的急性呼吸窘迫综合征患者（6/8例拔管; P < 0.001）分别维持了92、69和38%的体外膜肺氧合天数（P = 0.021）。在入组研究的所有23例患者中，气体流量增加（从2.3 +/- 2.2升/分钟增加到9.2 +/- 3.2升/分钟）确定呼吸频率（从29 ; 6次/分钟减少到8 ; 9次/分钟）和食管压力波动（从20 +/- 9到4 +/- 4 cm H2O;所有患者P < 0.001）。所有的COPD和桥梁肺移植患者的反应（达到救济阈值），而50%的急性呼吸窘迫综合征患者的nonresponses.Conclusions：二氧化碳清除通过体外膜肺氧合减轻呼吸工作，并允许拔管在许多患者中，主要是桥梁肺移植和COPD。只有少数急性呼吸窘迫综合征患者能够进行自主呼吸试验，其中约50%的患者，去除患者产生的大量二氧化碳不足以防止潜在有害的自主呼吸努力。
Background: We evaluate the clinical feasibility of spontaneous breathing on extracorporeal membrane oxygenation and the interactions between artificial and native lungs in patients bridged to lung transplant or with acute exacerbation of chronic obstructive pulmonary disease (COPD) or acute respiratory distress syndrome.Methods: The clinical course of a total of 48 patients was analyzed. Twenty-three of 48 patients were enrolled in the prospective study (nine bridged to lung transplant, six COPD, and eight acute respiratory distress syndrome). The response to the carbon dioxide removal was evaluated in terms of respiratory rate and esophageal pressure swings by increasing ("relief" threshold) and decreasing ("distress" threshold) the extracorporeal membrane oxygenation gas flow, starting from baseline condition.Results: Considering all 48 patients, spontaneous breathing extracorporeal membrane oxygenation was performed in 100% bridge to lung transplant (9 of 9 extubated), 86% COPD (5 of 6 extubated), but 27% acute respiratory distress syndrome patients (6 of 8 extubated; P < 0.001) and was maintained for 92, 69, and 38% of the extracorporeal membrane oxygenation days (P = 0.021), respectively. In all the 23 patients enrolled in the study, gas flow increase (from 2.3 +/- 2.2 to 9.2 +/- 3.2 l/min) determined a decrease of both respiratory rate (from 29 ; 6 to 8 ; 9 breaths/min) and esophageal pressure swings (from 20 +/- 9 to 4 +/- 4 cm H2O; P < 0.001 for all). All COPD and bridge to lung transplant patients were responders (reached the relief threshold), while 50% of acute respiratory distress syndrome patients were nonresponders.Conclusions: Carbon dioxide removal through extracorporeal membrane oxygenation relieves work of breathing and permits extubation in many patients, mainly bridge to lung transplant and COPD. Only few patients with acute respiratory distress syndrome were able to perform the spontaneous breathing trial, and in about 50% of these, removal of large amount of patient's carbon dioxide production was not sufficient to prevent potentially harmful spontaneous respiratory effort.