Forty-three patients were entered in an uncontrolled study designed to evaluate extracorporeal membrane lung support in severe acute respiratory failure of parenchymal origin. Most of the metabolic carbon dioxide production was cleared through a low-flow venovenous bypass. To avoid lung injury from conventional mechanical ventilation, the lungs were kept "at rest" (three to five breaths per minute) at a low peak airway pressure of 35 to 45 cm H2O (3.4 to 4.4 kPa). The entry criteria were based on gas exchange under standard ventilatory conditions (expected mortality rate, >90%). Lung function improved in thirty-one patients (72.8%), and 21 patients (48.8%) eventually survived. The mean time on bypass for the survivors was 5.4 ± 3.5 days. Improvement in lung function, when present, always occurred within 48 hours. Blood loss averaged 1800±850 mL/d. No major technical accidents occurred in more than 8000 hours of perfusion. Extracorporeal carbon dioxide removal with low-frequency ventilation proved a safe technique, and we suggest it as a valuable tool and an alternative to treating severe acute respiratory failure by conventional means. (JAMA1986;256:881-886)

/pdf/low-frequency-positive-pressure-ventilation-with-1tq7t6hhx1.pdf

Low-frequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure.

Extracorporeal Carbon Dioxide Removal and Low-Frequency Positive-Pressure Ventilation: Improvement in Arterial Oxygenation With Reduction of Risk of Pulmonary Barotrauma in Patients With Adult Respiratory Distress Syndrome

Using an animal model of acute respiratory failure (ARF), we evaluated two treatments: conventional mechanical pulmonary ventilation (MV) and continuous positive airway pressure (CPAP) with extracorporeal removal of CO2 by an artificial membrane lung. We developed a model of “mild” ARF and a model of “severe” ARF after ventilating healthy sheep at a peak inspiratory pressure of 50 cm H2O for various lengths of time. Sheep from either injury models were randomly assigned to one of the above treatment groups.All 16 sheep from the model with “severe” ARF died, with progressive deterioration in pulmonary function and multiorgan failure irrespective of the treatment. Of 11 sheep from the model with “mild” ARF treated by MV, only three survived, whereas all 11 sheep from the model with “mild” ARF treated with CPAP and extracorporeal removal of CO2 responded well, and nine sheep ultimately recovered.We conclude that CPAP with extracorporeal removal of CO2 provided a better environment for the recovery in our mod...

Severe acute respiratory failure managed with continuous positive airway pressure and partial extracorporeal carbon dioxide removal by an artificial membrane lung. A controlled, randomized animal study.

Extracorporeal lung assist (ELA) has been recommended for the treatment of ARDS if conventional therapy fails. However, the need for nearly complete anticoagulation is a major risk factor for hemorrhagic complications. We describe our experience with 13 ARDS patients treated with ELA using heparin-coated systems (Carmeda). Maintaining partial thromboplastin time and activated clotting time within or close to the normal range, even major surgery (20 thoracotomies and 2 laparotomies) could be performed without undue bleeding complications related to anticoagulation during extracorporeal support. Eight of the 13 patients survived. The use of heparin-coated systems allows prolonged ELA with nearly physiological coagulation function, permitting major surgical intervention. It enhances the safety margin of extracorporeal gas exchange and may ultimately extend its indications.

Extracorporeal lung assist with heparin-coated systems.

Total extracorporeal lung assist (ECLA) requires a bypass flow approaching cardiac output. Recirculation of venous blood through the oxygenator is minimized with a veno-right ventricular cannulation technique which separates venous drainage from returned oxygenated blood. A case of posttraumatic ARDS was treated with surface-heparinized veno-right ventricular ECLA for 35 days. Cardiac output was stabilized by means of sedation, hypothermia (35 degrees C) and beta blockers (pulse rate less than 90) in order to match the maximal venous drainage achieved (5.5 l/min). A bypass flow around 85% of cardiac output resulted in mean arterial PO2 values between 9-13.6 kPa without any contribution from the lungs. Low platelet counts and a marked bleeding tendency complicated treatment, even though no heparin was used during the last 24 days of ECLA. Weaning from the ventilator was accomplished 2 months after ECLA. Lung function tests show constant improvement.

https://link.springer.com/content/pdf/10.1007/BF01691426.pdf

Total extracorporeal lung assist--a new clinical approach.

Hematologic survey during low frequency positive pressure ventilation with extracorporeal CO2 removal.

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.

Extracorporeal carbon dioxide removal in acute respiratory failure.

PGI2 plus very low dose of heparin was infused in 6 lambs connected for long term extracorporeal circulation with a membrane lung. Hemodynamic and hemostasis parameters were compared to those of a control group treated only with standard doses of heparin. PGI2 efficacy in inhibiting platelet aggregation and platelet fall was confirmed. A small platelet release, measured as antiheparin activity, was observed during all the by-pass, but did not influence platelet capacity of recovering when PGI2 effect dissolved. Heparin needed resulted less than a quarter of the quantity used for the control group. In our experimental conditions the hemodynamic changes were mainly limited to a decrease in diastolic blood pressure.

Effect of PGI2 infusion during long term extracorporeal circulation with membrane lung in sheep.

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Hematologic survey during low frequency positive pressure ventilation with extracorporeal CO2 removal.

Extracorporeal carbon dioxide removal in acute respiratory failure.

Effect of PGI2 infusion during long term extracorporeal circulation with membrane lung in sheep.