Contemporary extracorporeal membrane oxygenation for adult respiratory failure: life support in the new era.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been used in clinical medicine for 40 years but remains controversial therapy, particularly in adult patients with severe respiratory failure. Over the last few years, there have been considerable advances in extracorporeal technology and clinical practice, ushering in a new era of ECMO. Many institutions adopted ECMO as rescue therapy during the recent H1N1 influenza pandemic, reigniting the controversy. DISCUSSION: Hollow-fibre oxygenators and Mendler-designed centrifugal pumps have replaced the old silicon oxygenators and roller pumps. The advantages of these novel systems and the principles that underlie their function are outlined. Advances in cannula technology allow greater ease of patient positioning, in some cases facilitating extubation and ambulation on ECMO. Improvements in ECMO circuitry have led to a reduction in heparin and blood product requirements, with consequently fewer complications. Greater understanding of severe acute respiratory distress syndrome has allowed clinicians to successfully support adults on ECMO for months at a time, as a bridge to either recovery or transplantation.
CONCLUSIONS: ECMO is safer, cheaper, and simpler than in previous eras. Both circuit and patient can be cared for by a single trained nurse. Additional prospective studies of ECMO for adult respiratory failure are underway. Contemporary ECMO in awake, potentially ambulant patients to provide short-term support for those with acute, reversible respiratory failure and as a bridge to transplantation in those with irreversible respiratory failure is now ready for widespread evaluation.