Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, 75013, Paris, France.
Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, 75013, Paris, France.
Intensive Care Med. 2020 Dec;46(12):2464-2476. doi: 10.1007/s00134-020-06290-1. Epub 2020 Nov 2.
Extracorporeal life support (ECLS) can support gas exchange in patients with the acute respiratory distress syndrome (ARDS). During ECLS, venous blood is drained from a central vein via a cannula, pumped through a semipermeable membrane that permits diffusion of oxygen and carbon dioxide, and returned via a cannula to a central vein. Two related forms of ECLS are used. Venovenous extracorporeal membrane oxygenation (ECMO), which uses high blood flow rates to both oxygenate the blood and remove carbon dioxide, may be considered in patients with severe ARDS whose oxygenation or ventilation cannot be maintained adequately with best practice conventional mechanical ventilation and adjunctive therapies, including prone positioning. Extracorporeal carbon dioxide removal (ECCOR) uses lower blood flow rates through smaller cannulae and provides substantial CO elimination (~ 20-70% of total CO production), albeit with marginal improvement in oxygenation. The rationale for using ECCOR in ARDS is to facilitate lung-protective ventilation by allowing a reduction of tidal volume, respiratory rate, plateau pressure, driving pressure and mechanical power delivered by the mechanical ventilator. This narrative review summarizes physiological concepts related to ECLS, as well as the rationale and evidence supporting ECMO and ECCOR for the treatment of ARDS. It also reviews complications, limitations, and the ethical dilemmas that can arise in treating patients with ECLS. Finally, it discusses future key research questions and challenges for this technology.
体外生命支持 (ECLS) 可在急性呼吸窘迫综合征 (ARDS) 患者中进行气体交换。在 ECLS 过程中，静脉血通过导管从中心静脉中抽出，通过允许氧气和二氧化碳扩散的半透膜泵出，并通过导管返回中心静脉。使用两种相关形式的 ECLS。静脉-静脉体外膜氧合 (ECMO) ，使用高血流速度来给血液充氧并去除二氧化碳，可用于那些严重 ARDS 患者，他们的氧合或通气不能通过最佳常规机械通气和辅助治疗（包括俯卧位）来充分维持。体外二氧化碳去除 (ECCOR) 通过较小的导管使用较低的血流速度，并提供大量的 CO 去除（约 20-70%的总 CO 产生），尽管在氧合方面有轻微改善。在 ARDS 中使用 ECCOR 的基本原理是通过允许降低潮气量、呼吸频率、平台压、驱动压和机械通气机输送的机械功率，从而促进肺保护性通气。本叙述性综述总结了与 ECLS 相关的生理概念，以及 ECMO 和 ECCOR 治疗 ARDS 的原理和证据。它还回顾了治疗 ECLS 患者时可能出现的并发症、限制和伦理困境。最后，它讨论了该技术未来的关键研究问题和挑战。
