ABSTRACT
PURPOSE: ECMO can provide a bridge to transplantation and improve survival for patients with advanced lung disease. Although pulmonary function testing (PFT) is an important component of the lung allocation score (LAS), it is not always feasible on patients requiring ECMO. While generally safe, PFT testing has contraindications and is not recommended in unstable patients. Currently there are no recommendations regarding the performance of spirometry in ECMO patients. STUDY DESIGN: and Methods: We reviewed data on five patients with advanced lung disease requiring ECMO-bridge to transplant. After careful consideration of the theoretical physiologic risks associated with forced expiratory maneuvers, bedside spirometry was performed in order to update the patients' LAS. RESULTS: All patients successfully completed three forced expiratory maneuvers in the seated position with a bedside spirometer. Vital signs and ECMO flow were stable during testing and without complication. In 2 patients who had both a LAS pre and post spirometry, the LAS increased by 3-5 points. CONCLUSION: Spirometry results are pivotal to organ allocation under current organ sharing protocols. This case series demonstrates that bedside spirometry testing may be performed safely in patients on ECMO awaiting lung transplantation without appreciable side effects, leading to a more accurate LAS score.
ABSTRACT
BACKGROUND: The current standard of analyzing microcirculatory video microscopy is time-consuming and occurs away from the patient, limiting its clinical utility. Point-of-care assessment with incident dark field (IDF) microscopy, however, may offer greater clinical applicability. We aimed to determine the reproducibility of the Point of Care Microcirculation (POEM) tool when used at the bedside in critically ill patients. METHODS: A multinational, multicenter, prospective observational study of adult intubated patients was undertaken during a 9-month period in Germany, the United Kingdom, and the United States. A user recorded a batch of four standardized video clips from each patient, calculated a POEM score and recorded the time for image acquisition. A second user blinded to the first repeated this process. Patients with video clips of poor quality were excluded. At a later date, the two users again blinded themselves to reassess both their own clips and those of the other user. Basic demographic information was recorded. Intrauser reliability (an individual user rescoring the same batch of videos after blinding), interuser reliability (a second user rescoring the other user's video batch after blinding), and test-retest reliability (two users individually capturing videos and recording POEM scores) were assessed using a linearly weighted kappa statistic for ordinal data. RESULTS: Sixty-five patients were included in the final analysis. Observer agreement was substantial for all tests. Intrauser agreement was 0.73 (0.95 CI 0.64-0.81), interuser agreement 0.71 (0.95 CI 0.63-0.79), and test-retest agreement 0.75 (0.95 CI 0.65-0.86). Average time to record videos and assess POEM scores 7:34â± 3:37 minutes. CONCLUSIONS: Point-of-care assessment of the microcirculation using IDF video microscopy and POEM scoring appears to be both a feasible and reproducible approach to microcirculatory assessment. Testing of the score in critically ill patients showed substantial agreement within and between investigators, but further studies should validate its utility as a tool to guide shock resuscitation.
