PDF(Pubmed)
Abstract：
Extracorporeal life support (ECLS) for acute respiratory failure encompasses veno-venous extracorporeal membrane oxygenation (V-V ECMO) and extracorporeal carbon dioxide removal (ECCO2R). V-V ECMO is primarily used to treat severe acute respiratory distress syndrome (ARDS), characterized by life-threatening hypoxemia or ventilatory insufficiency with conventional protective settings. It employs an artificial lung with high blood flows, and allows improvement in gas exchange, correction of hypoxemia, and reduction of the workload on the native lung. On the other hand, ECCO2R focuses on carbon dioxide removal and ventilatory load reduction (\"ultra-protective ventilation\") in moderate ARDS, or in avoiding pump failure in acute exacerbated chronic obstructive pulmonary disease. Clinical indications for V-V ECLS are tailored to individual patients, as there are no absolute contraindications. However, determining the ideal timing for initiating extracorporeal respiratory support remains uncertain. Current ECLS equipment faces issues like size and durability. Innovations include intravascular lung assist devices (ILADs) and pumpless devices, though they come with their own challenges. Efficient gas exchange relies on modern oxygenators using hollow fiber designs, but research is exploring microfluidic technology to improve oxygenator size, thrombogenicity, and blood flow capacity. Coagulation management during V-V ECLS is crucial due to common bleeding and thrombosis complications; indeed, anticoagulation strategies and monitoring systems require improvement, while surface coatings and new materials show promise. Moreover, pharmacokinetics during ECLS significantly impact antibiotic therapy, necessitating therapeutic drug monitoring for precise dosing. Managing native lung ventilation during V-V ECMO remains complex, requiring a careful balance between benefits and potential risks for spontaneously breathing patients. Moreover, weaning from V-V ECMO is recognized as an area of relevant uncertainty, requiring further research. In the last decade, the concept of Extracorporeal Organ Support (ECOS) for patients with multiple organ dysfunction has emerged, combining ECLS with other organ support therapies to provide a more holistic approach for critically ill patients. In this review, we aim at providing an in-depth overview of V-V ECMO and ECCO2R, addressing various aspects of their use, challenges, and potential future directions in research and development.
摘要：
急性呼吸衰竭的体外生命支持（ECLS）包括静脉-静脉体外膜氧合（V-VECMO）和体外二氧化碳去除（ECCO2R）。V-VECMO主要用于治疗严重急性呼吸窘迫综合征（ARDS），以威胁生命的低氧血症或常规保护设置的通气功能不全为特征。它采用了高血流量的人造肺，并改善气体交换，纠正低氧血症，并减少天然肺的工作量。另一方面,ECCO2R专注于中度ARDS中的二氧化碳去除和通风负荷降低（“超保护性通风”），或避免急性加重的慢性阻塞性肺疾病的泵衰竭。V-VECLS的临床适应症是针对个体患者量身定制的，因为没有绝对的禁忌症。然而,确定启动体外呼吸支持的理想时机仍不确定。当前的ECLS设备面临尺寸和耐用性等问题。创新包括血管内肺辅助装置（ILAD）和无泵装置，尽管他们有自己的挑战。高效的气体交换依赖于使用中空纤维设计的现代充氧器，但是研究正在探索微流体技术来改善充氧器的尺寸，血栓形成性,和血液流动能力。由于常见的出血和血栓形成并发症，在V-VECLS期间的凝血管理至关重要;确实，抗凝策略和监测系统需要改进，而表面涂层和新材料显示出希望。此外，ECLS期间的药代动力学显著影响抗生素治疗，需要精确给药的治疗药物监测。在V-VECMO期间管理天然肺通气仍然很复杂，要求在自主呼吸患者的益处和潜在风险之间保持谨慎的平衡。此外，从V-VECMO断奶被认为是一个相关不确定性领域，需要进一步研究。在过去的十年里，针对多器官功能障碍患者的体外器官支持（ECOS）的概念已经出现，将ECLS与其他器官支持疗法相结合，为危重病人提供更全面的治疗方法。在这次审查中,我们的目标是提供V-VECMO和ECCO2R的深入概述，解决它们使用的各个方面，挑战,和潜在的未来研究和发展方向。
