Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON; Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada.
Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON; Extracorporeal Life Support Program, Toronto General Hospital, Toronto, ON, Canada.
Chest. 2020 Sep;158(3):1036-1045. doi: 10.1016/j.chest.2020.04.016. Epub 2020 Apr 21.
ARDS is a lethal form of acute respiratory failure, and because no specific treatments exist, supportive care remains the primary management strategy in these patients. Extracorporeal membrane oxygenation (ECMO) has emerged as an intervention in patients with severe ARDS to facilitate gas exchange and the delivery of more lung protective ventilation. Over the past 20 years, improvements in ECMO technology have increased its safety and transportability, making it far more available to this patient population globally. Deciding which patients with ARDS should be initiated on ECMO remains a challenging question. Numerous clinical and laboratory markers have been investigated, and multiple risk scores developed, to aid physicians in this decision-making process. However, they are still imperfect, and the choice is often based on institutional guidelines and the clinical impression of the treating physician. Given the potential risks and resource implications for this intervention, patient selection is critical and it is important to provide ECMO only to patients who have a reasonable chance for recovery or bridge to transplantation. In patients undergoing ECMO where there is no potential for recovery or transplant, the only option may be withdrawal of ECMO and palliation. These patients may be awake and interactive, which is often a very challenging scenario for patients, families, and the clinical team. In this article, we present a more controversial case and a review of the literature regarding the selection of patients with ARDS who should receive ECMO.
急性呼吸窘迫综合征（ARDS）是一种致命形式的急性呼吸衰竭，由于没有特定的治疗方法，支持性治疗仍然是这些患者的主要治疗策略。体外膜肺氧合（ECMO）已成为治疗严重 ARDS 患者的一种干预措施，以促进气体交换和提供更具肺保护的通气。在过去的 20 年中，ECMO 技术的改进提高了其安全性和可运输性，使其在全球范围内更广泛地应用于这一患者群体。决定哪些 ARDS 患者应开始接受 ECMO 治疗仍然是一个具有挑战性的问题。已经研究了许多临床和实验室标志物，并开发了多个风险评分，以帮助医生在这个决策过程中。然而，它们仍然不完美，选择通常基于机构指南和治疗医生的临床印象。鉴于这种干预措施的潜在风险和资源影响，患者选择至关重要，重要的是仅为有合理恢复或移植机会的患者提供 ECMO。在接受 ECMO 治疗但没有恢复或移植可能的患者中，唯一的选择可能是停止 ECMO 并进行姑息治疗。这些患者可能是清醒和互动的，这对患者、家属和临床团队来说通常是一个非常具有挑战性的情况。在本文中，我们提出了一个更具争议性的病例，并回顾了关于应接受 ECMO 治疗的 ARDS 患者选择的文献。
