Successful Rescue Therapy with Pumpless Extracorporeal Carbon Dioxide Removal in a Patient with Persistent Air Leakage Due to Empyema / 대한중환자의학회지

A young metastatic lung cancer patient developed empyema due to an infection with carbapenem-resistant Acinetobacter baumannii. Hydropneumothorax was detected and managed by a tube thoracotomy. However, persistent air leakage through the chest tube was observed due to the presence of a bronchopleural fistula (BPF). As hypercapnic respiratory failure had progressed and the large air leak did not diminish by conservative management, a pumpless extracorporeal lung assist (pECLA) device was inserted. The pECLA allowed the patient to be weaned from mechanical ventilation and the BPF to heal. The present case shows the effective application of pECLA in a patient with empyema complicated with BPF and severe hypercapnic respiratory failure. pECLA enabled us to minimize airway pressure to aid in the closure of the BPF in the mechanically ventilated patient.

Successful Rescue Therapy with Pumpless Extracorporeal Carbon Dioxide Removal in a Patient with Persistent Air Leakage Due to Empyema / 대한구급학회지

A young metastatic lung cancer patient developed empyema due to an infection with carbapenem-resistant Acinetobacter baumannii. Hydropneumothorax was detected and managed by a tube thoracotomy. However, persistent air leakage through the chest tube was observed due to the presence of a bronchopleural fistula (BPF). As hypercapnic respiratory failure had progressed and the large air leak did not diminish by conservative management, a pumpless extracorporeal lung assist (pECLA) device was inserted. The pECLA allowed the patient to be weaned from mechanical ventilation and the BPF to heal. The present case shows the effective application of pECLA in a patient with empyema complicated with BPF and severe hypercapnic respiratory failure. pECLA enabled us to minimize airway pressure to aid in the closure of the BPF in the mechanically ventilated patient.

A Case of Pumpless Interventional Lung Assist Application in a Tuberculosis Destroyed Lung Patient with Severe Hypercapnic Respiratory Failure / 대한구급학회지

Pumpless extracorporeal interventional lung assist (iLA) is a rescue therapy allowing effective carbon dioxide removals and lung protective ventilator settings. Herein, we report the use of a pumpless extracorporeal iLA in a tuberculosis destroyed lung (TDL) patient with severe hypercapnic respiratory failures. A 35-year-old male patient with TDL was intubated due to CO2 retention and altered mentality. After 11 days, Ventilator Associated Pneumonia (VAP) had developed. Despite the maximal mechanical ventilator support, his severe respiratory acidosis was not corrected. We applied the iLA for the management of refractory hypercapnia with respiratory acidosis. This case suggests that the iLA is an effective rescue therapy for TDL patients with ventilator refractory hypercapnia.

Comparison of the Effect of Femoro-Femoral Extracorporeal Lung Assist(ECLA) and Jugulo-Carotid ECLA on the Systemic Oxygenation in Dogs / 대한마취과학회지

The extracorporeal respiratory support has (ECMO) or extracorporeal lung assist (ECLA). Jugulocarotid(JC) ECLA, which drains venous blood via the internal jugular vein and perfuses via the common carotid artery, is recognized as a therapeutic modality for acute respiratory failure of neonates. But recent follow-up studies report the possible neurologic complications after the ligation of the carotid artery. Femoro-femoral (FF) bypass is reported to be effective in cardiac support during cardiopulmonary resuscitation. Surgical approach of FF bypass is easier because of the superficial location of great vessels. To evaluate the cardiorespiratory support of FF bypass, twelve mongrel dogs were divided into JC and FF groups(n6 in each group) and ventilated artificially at F1O2 of 0.3 and 0.15 in a dog. While ventilating the oxygenator with N2 gas, control hemodynamic and blood gas values were obtained at FO1O2 0.3 and at F1O2 0.15. The values during VA ECLA in both groups were measured while flushing O2 gas into the oxygenator. We compared bypass flows and oxygenation effects between two groups. l) The comparison between JC ECLA and FF ECLA in F1O2 0.3 Mean arterial pressure (MAP) and cardiac output (CO) increased in both groups and mean pulmonary arterial pressure (MPAP) decreased in JC group. Bypass flow rates were 86+/-6ml/kg/min in JC group and 62+/-8 ml/kg/min in FF group. 2) The comparison between JC ECLA and FF ECLA in FO 0.15 MAP and CO increased in both groups and MPAP decreased in JC group. VA ECLA increased the arterial oxygen tension from 49+/-12 mmHg to 93+/-20 mmHg in JC group and from 54+/-14 mmHg to 77+/-12 mmHg in FF group. Bypass flow rates were 103+/-21 ml/kg/min in JC group and 67+/-12 ml/kg/min in FF group. The amount of changes of deltaPaO2(y) related to bypass ratio(x) was same between two groups The systemic oxygenation effect of FF ECLA in hypoxia was as efficient as that of JC ECLA. In conclusion, FF ECLA can be adopted for acute respiratory failure in which PaO2 is maintained about 50mmHg.

The Effect of Venovenous Extracorporeal Lung Assist on the Arterial Oxygen Tension in Hypoxic Dogs / 대한마취과학회지

Neonatal venoarterial(VA) extracorporeal lung assist(ECLA) drains venous blood from the right atrium via the right internal jugular vein and perfuses oxygenated blood to the aortic arch via the right common carotid artery. Though VA ECLA supports cardiac function, it is not free from neurologic complications due to ligation of the carotid artery. Venovenous(VV) bypass is used early for acute respiratory failure. To reduce the number of veins ligated, a double lumen tube was developed. VV ECLA using the double lumen tube was tried on eight hypoxic dogs at F1O2 0.15. Control values of hemodynamics and blood gases were obtained while the 0.8 m kolobow lung ventilated with nitrogen gas. We measured the same parameters while ventilating the oxygenator with oxygen(ECLA on). Mean arterial pressure and mean pulmonary arterial pressure were decreased significantly during ECLA on. Bypass flow rate was 1042+/-72ml/min and bypass ratio(bypass flow rate cardiac output X100) was 40+/-15%. Arterial oxygen tension was increased from 52+/-14mmHg to 79+/-23mmHg during ECLA on, whose saturation was 94+/-2%. Venous drainage was limited with a double lumen tube, but it can be used clinically for moderate hypoxemia with ease.

The Effect of Venoarterial Extracorporeal Lung Assist ( ECLA ) Using a Small - sized Membrane Oxygenator in Hypoxic Dogs / 대한마취과학회지

After the heart-lung machine was used for the open heart surgery, it was hypothesized that the extracorporeal circulation might be applicable to the management of acute respiratory failure. The development of silicone membrane minimized the possible physical or chemieal damages to blood perfused into the oxygenator. Extracorporeal lung assist(ECLA) using a membrane oxygenator has been recognized as a therapeutic modality for acute respiratory failure, To simplify and reduce the voulme of the ECLA circuit, a small oxygenator, surface area 0.3 m2, was developed by Kurare Co., Japan. It was composed of non-microporous hollow fibers. We performed venoarterial(VA) ECLA to evaluate the gas transfer of the Kurare oxygenator. The priming volume of the ECLA circuit was about 150 ml. Venous blood was drained via the right external jugular vein. The maximum bypass flow rate was about l060 ml/min. Oxygenated blood was perfused into aortic arch via the right carotid artery. The increase of arterial oxygen tension was about 58 mmHg during VA ECLA. It was confirmed that Kurare oxygenator was adequate for the oxygenation support on hypoxic dogs. We tried this ECLA circuit on a postoperative cardiac patient on May, 20, 1991. After 90 hours VA ECLA, she recovered without any complicatioris.

The Effect of Venovenous Extracorporeal Lung Assist on the Pulmonary Circulation in Hypoxic Dogs / 대한마취과학회지

The effect of elevated mixed venous oxygen tension(PvO2) on the diffuse alveolar hypoxia was studied in dogs using venovenous(VV) extracorporeal lung assist(ECLA). Six mongrel dogs were mechanically ventilated with the continous infusion of pentobarbital. A double lumen tube was inserted via the right external jugular vein and was eonnected with the ECLA cireuit to establish a VV bypass. A Kurare oxygenator 0.3m2 was chosen to obviate the use of homologous blood for priming. The total volume of the ECLA circuit was 150mL Without ventilating the oxygenator during VV ECLA, we decreased F1O2 from 0.21 to 0.1 via 0.15 to evaluate the hypoxic repsonse of lung. Stepwise reductions in F1O2 0.21 to 0.l caused the arterial oxygen tension(PvO2) and (PvO2 to decrease while the mean pulmonary arterial pressure(MPAP) and pulmonary vascular resistance(PVR) progressively increased. We hypothesized that the reduction of F1O2 without aceompanying decrease of PvOmight not induce hypoxic pulmonary vasoconstriciton(HPV) which was proved at low F1O2 with low PvO VV ECLA was tried on another 7 dogs while monitoring arterial oxygen saturation(SaO2) and mixed venous oxygen saturation(SvO2) by two oximetrix catheters. The elevation of SvO2 during VV ECLA was followed by the elevation of SaO2 We compared MPAP and PVR at high F1O2 with those at low F1O2with VV ECLA while making SaO2 equal. PvO2 were 39+/-11mmHg at F1O2 0.21 and 62+/-11mmHg at F1O2 0.15 with VV ECLA. PvO2 were 30+/-8mmHg at F1O2 0.15 and 53+/-10mmHg at F1O2 0.1 with VV ECLA. MPAP and PVR were 18+/-5mmHg and 176+/-56 dyne sec/cm5 at F1O2 0.21 and 19+/-4mmHg and 198+/-94 dyne sec/cm5 at F1O2 0.15 with VV ECLA . MPAP and PVR were 25 5 mmHg and 430+/-250 dyne. sec/ cm5 at F1O2 0.15 and 25+/-5mmHg and 400+/-197 dyne sec/cm5 at F1O2 0.1 with VV ECLA. Decrease of F1O2 from 0.21 to 0.15 and from 0.15 to 0.1 did not cause significant ehanges in MPAP and PVR during VV ECLA. Our findings indicate that small increase of PvO2 by VV ECLA may prevent or diminish hypoxic resyonse of the whole lung.

Extracorporeal Membrane Oxygenation Support for Dogs in Acute Respiratory Failure : Comparison of venovenous extracorporeal lung assist using a double lumen tube with venoarterial extracorporeal lung assist / 대한마취과학회지

Mechanical ventilation is widely used for the respiratory support in patients with acute respiratory insufficiency. Extracorporeal respiratory support using a membrane oxygenator has been developed to relieve refractory hypoxemia or hypercapnea under conventional ventilatory management. It has been called extrcorporeal membrane oxygenation (ECMO), extracorporeal carbon dioxide removal (ECCO2R) or extracorporeal lung assist (ECLA). Venoarterial (VA) ECLA drains blood from a catheter placed in the right atrium via the internal jugular vein and perfuses through a cannula at the level of the aortic arch via the right common carotid artery. While VA ECLA supports the heart as well as the lungs, but it has the disadvantage of requiring carotid artery ligation. In venovenous (VV) ECLA, perfusion cannula is placed at a large vein and the carotid artery is not ligated. In addition there is theoretical advantage of perfusing the well oxygenated blood to pulmonary artery. We hypothesized that VV ECLA is as effective as VA ECLA in the oxygenation of arterial blood when the respiratory insufficiency does not accompany heart failure. A model of acute respiratory failure was induced on 6 dogs by the injection of oleic acid 0.07 ml/ kg. Two hours later, acute hypoxemia and hypercapnea were identified with acute hemorrhagic pulmonary edema, but the hemodynamic parameters were stable for 2 hours. Oleic acid 0.07 ml/kg was injected on another 7 dogs. A double lumen tube and a perfusion cannula were introduced via the right external jugular vein and the carotid artery, respectively. The outer lumen of a double lumen tube was used for the drainge of both VV ECLA and VA ECLA. Mixed venous oxygen tension (PvO2) was higer in VV ECLA than in VA ECLA, but arterial oxygen tensian (PaO2) in VV ECLA was as high as that in VA ECLA. It could be concluded that VV ECLA using a double lumen tube can be used as an alternative to VA ECLA for the respiratory support of acute respiratory failure.

The Effect of Venovenous Extracorporeal Lung Assist on the Oxygenation of Mixed Venous Blood : Comparison of venovenous bypass using a dulble lumen tube with that using two catheters / 대한마취과학회지

At the beginning of 1980's, respiratory support by extracorporeal circulation using a membrane oxygenator attracted medical attention again because it could provide the diseased lung with rest. The extracorporeal respiratory support has been called extracorporeal membrane oxygenation (ECMO), extracorporeal CO2, removal (ECCO2R) or extracorporeal lung assist (ECLA). They are the terms used to describe prolonged extracorporeal venoarterial (VA) or venovenous (VV) bypass via extrathoracic cannulation in patients with acute, reversible cardiac or respiratory failure refractory to conventional medical or pharmacologic management. Usually VV bypass is maintained by cannulating the superior vena cava through one major catheter and the inferior vena cava through another. To reduce the number of veins to be cannulated during VV bypass, a double lumen tube was designed. To compare VV ECLA using a double lumen tube with that using two catheters, we observed the changes of the PvO2 (delta PvO2) as a parameter of extracor-poreal oxygenation. A process from ECLA off to ECLA on was performed thirty-three times on 7 mongrel dogs by VV ECLA using a double lumen tube (double lumen group, 16.7+/-1.9 kg, mean+/-standard deviation) and thirty-four times on 6 mongrel dogs by that using two catheters (two-way bypass, control group, 16.1+/-3.0 kg). In double lumen group, bypass flow rate was 52.3+/-15.1ml/kg/min and bypass ratio (bypass flow/cardiac outputX100) was 65.0+/-25.3%. During ECLA off, PvO2, was 43.3+/-6.7 torr and it was raised to 70.1+/-15.4 torr during ECLA on (p<0.001). delta PvO2 was 27.2+/-17.8 torr. In control group, bypass flow rate was 56.1+/-20.5 ml/kg/min and bypass ratio was 72.3+/-29%. During ECLA off, PvO2, was 39.4+/-7.8 torr and it was raised to 58.4+/-3.9 torr during ECLA on (P<0.001). delta PvO2 was 18.3+/-7.9 torr. delta PvO2, of double lumen group was higher than that of control group (p<0.001). The rise of delta PvO2, (y) following the increaae of bypass ratio (x) was y= -6.54+0.50x (r=0.71, P< 0.001) in double lumen group, and y=0.67+0.26x (r=0.88, P<0.001) in control group. It could be concluded that the rise of PvO2 was obtained more efficiently in double lumen group than in eontrol group (p<0.001). A double lumen tube may permit the simplicity of an operation and patient care as well as minimizing the bleeding during clinical ECLA.