The Utilization of Venous-Venous Extracorporeal Membrane Oxygenation for the Management of Status Asthmaticus

Background:Life threatening refractory asthma requiring intubation and mechanical ventilation is often associated with a high incidence of ventilator induced trauma (VILI) and has a mortality rate of around eight percent. Often these patients present with high level of arterial PaCO2 which require both a high minute ventilation and airway pressures despite lung protective ventilation and the administration of Heliox gas mixture. These ventilator requirements place this patient population at risk for excessive auto-PEEP and barotrauma. Another approach to meet gas exchange goals and to provide maximum lung protective is to place these patients on venous-venous extracorporeal oxygenation membrane (ECMO) support. The clinical rational for this management would be to protect the lung from any additional VILI and provide a stable level of ventilation and acid-base balance. Methods:During a two year time frame we placed six status asthmaticus patients with refractory gas exchange on V-V ECMO. Five of the six patients were management on V-V ECMO until the asthma exacerbation was stabilized and progressed to both ECMO and ventilator liberation. One patient expired secondary to multi-system organ failure unrelated to asthma. All patients were ventilated via pressure or volume target modes to achieve an exhaled tidal volume between 4-5cc/kg/IBW and PEEP was set via either a pressure/volume tool or via transpulmonary monitoring. ECMO parameters we set to achieve a SpO2>88% and a PH>7. 25. Results:There was no additional occurrences of additional VILI post ECMO intervention. And all patients receive pharmacological paralytics, Heliox, and continuous beta-agonist therapy for the first forty hours of mechanical ventilation and ECMO support. (Table 1) Conclusions:Based on our clinical experiences, V-V ECMO along with lung protective ventilation can provide a safe management of the status asthmaticus with refractory gas exchange.V-V ECMO for Life threatening asthmaPatient #Age/GVent Mode/TV settingV-V ECMO LOSECMO FIO2/FlowExt ubation time from cannulationHelioxSurvival151/MPCMV4cc/kg/IBW7100%/5lpm120 hrs.YesYes228/MCMV4cc/kg/IBW8100%/9 lpm70 hrs.YesYes349/MPCMV 5cc/kg/IBW5100%/4.5 lpm42 hrs.YesYes431/FPCMV5cc/kg/IBW1580%/ 3lpmNAYesNo518/MCMV4cc/kg/IBW880%/4 lpm209 hrs.YesYes631/FPCMV4cc/kg/IBW9100/1.5 lpm52 hrs.YesYesAll pts. received continuous beta-agonist delivery PEEP setting were guided by transpulmonary E