Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA.
Artif Organs. 2021 Jun;45(6):559-568. doi: 10.1111/aor.13861. Epub 2021 Jan 25.
Modern extracorporeal life-support (ECLS) technology has been successfully utilized to treat patients with diffuse alveolar damage (DAD) and diffuse alveolar hemorrhage (DAH); however, reports in the literature remain scarce. We sought to pool existing evidence to better characterize ECLS use in these patients. An electronic search was conducted to identify all studies in the English literature reporting the use of ECLS for DAD/DAH. Thirty-two articles consisting of 38 patients were selected, and patient-level data were extracted and pooled for analysis. Median patient age was 36 [IQR: 27, 48] years, and the majority (63.2%) were female. Most common etiological factors included granulomatosis with polyangiitis (8/38, 21.1%), systemic lupus erythematosus (8/38, 21.1%), Goodpasture's syndrome (4/38, 10.5%), and microscopic polyangiitis (4/38, 10.5%). Immunologic markers included anti-neutrophil cytoplasmic antibody (ANCA) in 15/38 (39.5%), anti-nuclear antibody (ANA) in 6/38 (15.8%), and anti-glomerular basement membrane (anti-GBM) antibodies in 4/38 (10.5%). DAH was present in 32/38 (84.2%) of cases and DAD without evidence of DAH was present in 6/38 (15.8%) of cases. ECLS strategies included extracorporeal membrane oxygenation of veno-venous type (VV-ECMO) in 28/38 (73.7%), veno-arterial type (VA-ECMO) in 5/38 (13.2%), and one case of right ventricular assist device with oxygenator (RVAD-ECMO). Heparin was utilized in 18/38 (47.4%) of cases with no difference in use between DAH versus no DAH (P = .46) or VA- versus VV-ECLS (P = 1). Median duration of ECLS was 10 [5, 14] days. Pre- versus post-ECLS comparison of blood gases showed improvement in median PaO (49 [45, 59] mm Hg vs. 80 [70, 99] mm Hg, P < .001), PaO2:FiO ratio (48.2 [41.4, 54.8] vs. 182.0 [149.4, 212.2], P < .01), and pulse oximetry values (76% [72, 80] vs. 96% [94, 97], P = .086). Overall, 94.7% (36/38) of patients survived to decannulation while 30-day mortality was 10.5% (4/38) with no differences between VA- and VV-ECMO (P = 1 and P = .94, respectively). DAD/DAH occurs in a younger, predominantly female population, and tends to be associated with systemic autoimmune processes. ECLS, independent of its type, appears to result in favorable short-term survival.
现代体外生命支持（ECLS）技术已成功用于治疗弥漫性肺泡损伤（DAD）和弥漫性肺泡出血（DAH）患者；然而，文献中的报道仍然很少。我们试图汇集现有证据，以更好地描述这些患者使用 ECLS 的情况。进行了电子检索，以确定所有报道 ECLS 用于 DAD/DAH 的英文文献中的研究。选择了 32 篇文章，共 38 例患者，提取并汇总患者水平数据进行分析。中位患者年龄为 36 [IQR：27，48] 岁，大多数（63.2%）为女性。最常见的病因因素包括肉芽肿性多血管炎（8/38，21.1%）、系统性红斑狼疮（8/38，21.1%）、Goodpasture 综合征（4/38，10.5%）和显微镜下多血管炎（4/38，10.5%）。免疫标志物包括抗中性粒细胞胞质抗体（ANCA）15/38（39.5%）、抗核抗体（ANA）6/38（15.8%）和抗肾小球基底膜（抗-GBM）抗体 4/38（10.5%）。32/38（84.2%）例存在 DAH，6/38（15.8%）例存在无 DAH 的 DAD。ECLS 策略包括静脉-静脉型（VV-ECMO）28/38（73.7%）、静脉-动脉型（VA-ECMO）5/38（13.2%）和 1 例带氧合器的右心室辅助装置（RVAD-ECMO）。18/38（47.4%）例使用肝素，在 DAH 与无 DAH（P=0.46）或 VA-与 VV-ECLS（P=1）之间使用肝素无差异。ECLS 的中位持续时间为 10 [5，14] 天。血气预与后 ECLS 比较显示 PaO 改善（中位数 49 [45，59] mm Hg 比 80 [70，99] mm Hg，P<0.001），PaO2:FiO 比值改善（中位数 48.2 [41.4，54.8] 比 182.0 [149.4，212.2]，P<0.01），脉搏血氧饱和度值改善（76% [72，80] 比 96% [94，97]，P=0.086）。总体而言，94.7%（36/38）的患者成功拔管，30 天死亡率为 10.5%（4/38），VA-与 VV-ECMO 之间无差异（P=1 和 P=0.94）。DAD/DAH 发生在年轻、以女性为主的人群中，往往与系统性自身免疫过程有关。ECLS，无论其类型如何，似乎都能带来有利的短期生存。
