Extracorporeal membrane oxygenation (ECMO) is a technique that improves the survival of patients with respiratory dysfunction in intensive care units. It is a complex procedure and the most severe cases may require long periods with ECMO, even for months. A multicenter study led by the Shock, Organ Dysfunction and Resuscitation research group at Vall d'Hebron Research Institute (VHIR) has shown that keeping ECMO patients awake, active and doing rehabilitation can improve their prognosis. This is a study in collaboration with the Pitié-Salpêtrière Hospital in Paris, the Karolinska Institute in Stockholm and the São João University Hospital in Porto and published in the journal Annals of the American Thoracic Society.

Since the beginning of the pandemic, Vall d'Hebron has been a reference in the use of ECMO in more than 125 patients with COVID-19. As these are very seriously ill patients, they are often sedated. "Despite this, even if their lungs are not functioning, it is possible to wake them up and perform active rehabilitation because the ECMO allows gas exchange as in breathing. In addition, the support can be adjusted according to the needs of each patient at each moment and increased while exercising", says Dr. Jordi Riera, director of the adult ECMO program at Vall d'Hebron University Hospital and principal investigator of the research group on Shock, Organ Dysfunction and Resuscitation at VHIR.

To understand the factors influencing the prognosis of ECMO patients and the benefits of the wake-up strategy, the research team conducted a study of 120 patients with COVID-19 respiratory dysfunction and ECMO requirements for more than 28 days. Among the results was the observation that, in patients who were cooperative and underwent rehabilitation and physiotherapy at some point during ECMO support, survival at six months was 78.8% and required less rehabilitation after discharge. In contrast, survival dropped to 41.4% in the most inactive cases.

"If they are awake, patients can interact with their relatives, which has cognitive and emotional benefits. In addition, if healthcare professionals can communicate with patients, a more accurate diagnosis can be made based on the symptoms they are explaining and, therefore, therapy can be better adjusted", argues Dr. Riera. This improvement in survival is also explained by the fact that waking patients up minimizes some complications. For example, they have fewer infections, thanks to the ability to cough, and less lung damage associated with ventilation is observed.

The study also observed that younger age favors survival. In addition, further research is needed to identify the characteristics of patients who require lung transplantation after COVID-19 as the only therapeutic option. The investigators emphasize that, despite requiring ECMO for one month, full recovery without the need for oxygen after support is possible.

It should be noted that the retrospective analysis only included patients who were on ECMO for more than 28 days and with the perspective of improvement, since mortality is higher in the most critical cases during the first weeks. Furthermore, despite being focused on patients with COVID-19, the researchers believe that these results could be generalizable to patients with respiratory dysfunction due to other causes.

More research to improve prognosis of ECMO patients

Vall d'Hebron is one of the world's leading centers in the use of ECMO due to the high number of patients treated. The quality of care stands out due to the adherence to the recommendations of international organizations, but also the participation in international research networks to improve survival and quality of life of patients.

Among these studies with Vall d'Hebron's participation is a paper recently published in American Journal of Respiratory and Critical Care Medicine as part of the PROTECMO study. This is an analysis of 652 patients from 41 centers focused on the risk of thrombus and bleeding associated with ECMO. Indeed, anticoagulation therapy is necessary while on support to prevent thrombus formation due to blood contact with an external surface, but guidelines are needed for the management of this treatment, as bleeding complications are common and transfusion is not without risk.

The risk of infections during ECMO is also an area of research interest. In this regard, the international study INFECMO has been launched. The trial, led by IRCCS Ca' Granda Ospedale Maggiore Policlinico in Milan and with the participation of Vall d'Hebron, seeks to understand the factors related to infections and the efficacy of different antibiotics for the treatment of this type of patient. Dr. Riera is the coordinator of the working group on infections in EuroELSO, the international reference society in ECMO.