Some patients with severe COVID-19, treated with extracorporeal membrane oxygenation (ECMO), may experience significant lung recovery and return to normal lives with “meaningful” long-term outcomes, according to follow-up research a year after the treatment, published in The Annals of Thoracic Surgery.
The findings also suggests that with some patients and aggressive strategies, EMCO support for severe COVID might result in exceptional early survival.
“Our work suggests that these patients, who leave the hospital without the need for oxygen therapy, are very likely to remain alive and well a year later,” said Dr Deane Smith from NYU Langone Health in New York.
Smith and colleagues identified 415 patients who were admitted to the intensive care unit of NYU Langone Health between 10 March 2020 and 1 May 2020 with confirmed COVID-19 infection. Of those, 30 (7.2%) received venovenous (VV) ECMO – an advanced life support machine that takes over the function of damaged lungs.
Most of the ICU patients – 323 (77.8%) – were intubated for mechanical ventilatory support. However, said Smith, the ventilator may damage the lungs further and “create a vicious cycle” for patients with severe lung disease or damage, who are intubated. In some cases, VV-ECMO could result in decreased support from the ventilator, minimising damage to the lungs and allowing them to begin healing.
Thus, 80 patients (19.3%) were evaluated for VV-ECMO, with 30 (7.2%) eventually receiving it.
“These patients received ECMO for severe COVID-19 during the height of the pandemic in New York City, at a time when very little was known about the likelihood for success,” said Smith. The researchers reported that 28 patients (93.3%) survived VV-ECMO.
These patients were hospitalised for a median of 45 days and supported on VV-ECMO for a median of 19 days. Importantly, 27 of them (90%) were discharged to either go home or to acute rehabilitation. None left the hospital dependent on a ventilator, and only one required supplemental oxygen.
Smith said patient selection was a significant factor affecting the success of VV-ECMO. The selection philosophy was that this was not a “bailout” or salvage therapy to be employed in the absence of other options. Instead, it was offered to patients thought to have a reasonable chance for survival with this support.
“We were struck by the number of young, otherwise healthy patients who were dying from the disease. Because of this, we felt patient selection was very important,” he said.
The decision to offer ECMO support was linked to the severity of lung disease and potential for survival. “If there were one theme throughout our experience, it was how we would define success. We did not feel that using ECMO to have patients survive simply to go to long-term facilities debilitated and vent-dependent was successful, or not as successful as it could be. In other words, we began with the end in mind. If we were going to offer patients ECMO for severe COVID-19, it was because we believed we could protect the lungs and allow patients to return to their normal lives at the end of it.”
While patient selection was important, a standardised approach to patient management and protecting the lungs was equally valuable. This included: not deviating from lung protective ventilation strategies, early tracheostomy (an opening surgically created through the neck into the trachea) and frequent bronchoscopy (looking directly at the airways using a thin, lighted tube), treatment of coinfection, and standardisation of an anticoagulation regimen (to help prevent blood clots). In addition, to help improve oxygenation, the team frequently positioned patients who were not recovering as fast as expected, on their abdomens, also known as “proning”.
“It’s worth noting that most things likes bronchoscopy or tracheostomy were not considered safe in patients with COVID-19 at the start of the pandemic,” added Smith. “Our team was aggressive with these interventions much earlier than most hospitals.”
Importantly, at a median follow-up of 10.8 months after being treated with VV-ECMO, patient survival was 86.7%, including one who underwent lung transplantation. A 6-minute walk test was performed on 16 patients (59.3%) with a median value of 350 metres, which the researchers called “encouraging”.
“We learned that lung recovery was actually possible. When the pandemic started, that was not clear,” said Smith.
Study details
One-Year Outcomes With Venovenous Extracorporeal Membrane Oxygenation Support for Severe COVID-19
Deane Smith, Stephanie Chang, Travis Geraci, Les James, Zachary Kon, Julius Carillo, Marjan Alimi, David Williams, Joshua Scheinerman, Robert Cerfolio, Eugene Grossi, Nader Moazami, Aubrey Galloway.
Published in The Annals of Thoracic Surgery on 9 March 2022
Abstract
Background
Severe coronavirus disease 2019 (COVID-19) can cause acute respiratory failure requiring mechanical ventilation. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) has been used in patients in whom conventional mechanical ventilatory support has failed. To date, published data have focused on survival from ECMO and survival to discharge. In addition to survival to discharge, this study reports 1-year follow-up data for patients who were successfully discharged from the hospital.
Methods
A single-institution, retrospective review of all patients with severe COVID-19 who were cannulated for VV-ECMO between March 10, 2020 and May 1, 2020 was performed. A multidisciplinary ECMO team evaluated, selected, and managed patients with ECMO support. The primary outcome of this study was survival to discharge. Available 1-year follow-up data are also reported.
Results
A total of 30 patients were supported with VV-ECMO, and 27 patients (90%) survived to discharge. All patients were discharged home or to acute rehabilitation on room air, except for 1 patient (3.7%), who required supplemental oxygen therapy. At a median follow-up of 10.8 months (interquartile range [IQR], 8.9-14.4 months) since ECMO cannulation, survival was 86.7%, including 1 patient who underwent lung transplantation. Of the patients discharged from the hospital, 44.4% (12/27) had pulmonary function testing, with a median percent predicted forced expiratory volume of 100% (IQR, 91%-110%). For survivors, a 6-minute walk test was performed in 59.3% (16/27), with a median value of 350 m (IQR, 286-379 m).
Conclusions
A well-defined patient selection and management strategy of VV-ECMO support in patients with severe COVID-19 resulted in exceptional survival to discharge that was sustained at 1-year after ECMO cannulation.
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