The use of extracorporeal membrane oxygenation (ECMO) in awake, spontaneously breathing patients (sometimes called “awake ECMO”) has been used for over a decade as a bridge for patients awaiting lung transplants. Cases have also been described where the therapy was used as an alternative to mechanical ventilation in COPD exacerbation.
In 2012, the first report of using venovenous ECMO support for the treatment of acute respiratory distress syndrome (ARDS) came out of Hannover Medical School, and research is ongoing in this area.
Today, as the world continues to confront the COVID-19 pandemic, the use of awake ECMO in the treatment of severe COVID-19 has produced promising results in early stage investigations.
Complications of Invasive Ventilation in COVID-19 Patients
Patients with severe COVID-19 infection can deteriorate rapidly thus requiring intubation and invasive ventilation. However, invasive respiratory support is not without complications which may include:
- Ventilator disconnection
- Ventilator associated pneumonia (VAP)
- Barotrauma due to excessive airway pressures
- Volutrauma damage due to excessive lung volumes
- Oxygen toxicity due to persistent high oxygen concentrations
Given these ventilator associated risks, some clinicians have been exploring the use of awake ECMO as an alternative treatment for severe COVID-19.
Awake ECMO for Severe COVID-19
Awake ECMO prior to intubation for severe COVID-19 is being tested by Jeffrey DellaVolpe, MD, medical director of the adult ECMO program at Methodist Hospital in San Antonio.
Before attempting ECMO, COVID-19 patients typically receive mechanical ventilation following the standard of care for severe ARDS using lung protective ventilator settings, prone positioning, and other strategies.
There have already been case reports of successful treatment of severe COVID-19 with awake extracorporeal membrane oxygenation. Della Volpe and his team at San Antonio now seek to confirm whether this is a viable treatment option. The goals of the study are to reveal whether awake ECMO reduces the need for ventilation and measure the impact on outcomes in critical COVID-19 cases.
Determining Early/Awake ECMO Efficacy
According to Dr. DellaVolpe, “The later you put ECMO on, the more time you expose them to harmful effects of the ventilator.”
Research at his center shows that when the application of ECMO is delayed for ventilated patients, there is an associated 56% increased risk of death after adjusting for covariates, including age, sex, and comorbidities.
One important obstacle to ECMO treatment is the lack of availability of equipment and qualified staff to administer the intervention. Meanwhile, DellaVolpe estimates that up to 80% of severe COVID-19 patients might fit criteria that show a benefit to early or awake ECMO.
For severe COVID-19 and other acute respiratory diseases, the use of ECMO is a valuable treatment to consider early during treatment. In the future, awake ECMO may even become the treatment of choice in selected cases.
Artificial lung as an alternative to mechanical ventilation in COPD exacerbation
Extracorporeal membrane oxygenation in a nonintubated patient with acute respiratory distress syndrome
COVID-19 disease: invasive ventilation
Successfully treatment of application awake extracorporeal membrane oxygenation in critical COVID-19 patient: a case report
Should ECMO Come Before Intubation for COVID-19?