Concise Critical Appraisal: Planning and Provision of ECMO for Severe ARDS From COVID-19

Our understanding of COVID-19 pneumonia is constantly evolving as deliberations continue daily regarding the risks, benefits, and timing of mechanical ventilation and various medication trials. The lungs of many patients with COVID-19 start with normal compliance and worsen to a high elastance/low compliance state that is consistent with acute respiratory distress syndrome (ARDS) (Gattinoni et al. Intensive Care Med. 2020 [Epub ahead of print]). World Health Organization interim guidelines recommend extracorporeal membrane oxygenation (ECMO) for eligible patients with severe ARDS related to COVID-19. Evidence from similar patient populations suggests that carefully selected patients with severe ARDS who do not benefit from conventional treatment might be successfully supported with venovenous ECMO. Ramanathan et al (Lancet Respir Med. 2020;8:518-526) outline how to plan for this complex therapy that is usually restricted to specialized centers and how this planning can help during other outbreaks of emerging infectious diseases.

The H1N1 pandemic was transformational for the ECMO community. The surge of patients resulted in a steady increase of ECMO-capable centers and the creation of strategic disaster planning. Aftermath research revealed promise for ECMO, with many success stories, despite evidence that mortality rates were difficult to determine because of many confounding factors, mainly the treatment course leading up to cannulation (Zangrillo et al. Crit Care. 2013;17:R30).

Infrastructure and resources to provide this lifesaving therapy have expanded rapidly over the past decade. Venovenous ECMO has quickly become a vital component of the management of severe refractory respiratory failure in ARDS. Ramanathan et al discuss a framework for building a sustainable system for patient management during global pandemics and times of increased resource use. They discuss how ECMO surge planning can be categorized into ensuring appropriate organization of four key components: personnel, equipment, facilities, and systems. They then discuss 10 key components of an ECMO action plan based on these four categories:

1. ECMO resource planning and allocation
2. Personnel assignment
3. Personnel training and ECMO use
4. Infection control measures before and during ECMO initiation
5. Transport of patients receiving ECMO
6. ECMO weaning, decannulation, and rehabilitation
7. Postmortem care
8. Staff support
9. Ethical considerations
10. Quality assurance and collaborative research

The authors note that additional efforts must be focused on quality assurance and collaborative research. This component is a vital part of the process because it can benefit any future respiratory-focused pandemic. It is imperative to drop all barriers limiting data sharing among research groups and to share data early in the process. It is only with open communication that we can make the most lasting benefits for the COVID-19 patient population.

The article represents an important addition to the global anthology of COVID-19 research. Ramanathan et al meticulously lay out all the steps required for using ECMO for this critically ill population. Even before the global pandemic, there were mixed opinions on the proper use of this vital technology and a demand for appropriate guidance. The authors highlight current important considerations in many organizations during the COVID-19 pandemic. Resource planning stands out as a rate-limiting factor for ECMO care due to its high use of resources. This can be a serious constraint because many U.S. organizations are experiencing supply chain disruptions and essential equipment shortages as well as complexities required to maintain a well-trained, experienced staff. Because a well-trained staff is one of the most vital resources, site-specific training needs to be implemented system-wide to increase the number of trained staff and prevent burnout.

One limitation of this article is the lack of direction in regard to the ethical considerations around the uncertainties of inclusion criteria, duration, and termination of ECMO. Further research is needed to provide evidence-based recommendations for these multifactorial complex cases.

With the increased use of ECMO, an effective system-wide action plan needs to be in place to help guide decisions during times of crisis. Further research is needed in both the management of COVID-19 and the efficacy and safety of ECMO therapy with this new disease process.

Authors of this installment of Concise Critical Appraisal:

Miles Monroe, PA-C, is a critical care physician assistant at Inova Fairfax Hospital.

David Phelps, ACNP-BC, is a critical care nurse practitioner at Inova Fairfax Hospital.

James H. Lantry III, MD, is an assistant professor of emergency and critical care medicine and the associate program director of the critical care fellowship at the University of Maryland Medical Center in Baltimore, Maryland, USA. Dr. Lantry is an editor of Concise Critical Appraisal.