Extracorporeal Membrane Oxygenation as a Bridge to Recovery in Patients with Idiopathic Pulmonary Fibrosis and Acute Respiratory Failure
Rachel Deitz, Ernest G. Chan, John P. Ryan, Masashi Furukawa, *Pablo G. Sanchez
Dept of Cardiothoracic Sugery , University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
Objective: Idiopathic pulmonary fibrosis (IPF) is a rare, progressive lung disease affecting around 100,000 patients in the US and 3 million worldwide. IPF hospital admissions are attributed to acute exacerbations either due to disease progression or pulmonary infection, both of which carry high mortality. In patients with disease progression lung transplant is the only viable therapy. However, in the case of infection or acute exacerbation, mechanical ventilation is the only option. Traditionally ECMO programs have not offered support to patients in respiratory failure with chronic lung disease if they are not potential transplant candidates. The goal of this analysis is to report outcomes of patients with IPF and acute respiratory failure in which ECMO was used as a bridge to recovery.
Methods: We performed a retrospective analysis of the ELSO registry and identified all patients with a diagnosis of fibrosis and accompanying acute respiratory failure or pneumonia who were supported on ECMO. Patients who were ultimately transplanted were excluded. Continuous variables were compared with Mann-Whitney U test, and categorical variables were compared with chi square. A p < 0.05 was considered statistically significant.
Results: During a 10 year period between 2010-2020, 1661 patients with IPF were placed on ECMO and 356 had concomitant pneumonia or acute respiratory failure. The median age was 60, and the cohort was predominantly white (n=225, 63%) and male (n=231, 65%). VV ECMO was initiated in 258 patients (72%) and VA ECMO was employed for the remaining 98 (28%). Pre-ECLS support was captured, with more than half of all patients (n=197, 55%) requiring vasopressors or inotropic support. Use of vasopressors/inotropes, alkali therapy, narcotics, neuromuscular blockers, and renal replacement therapy was associated with mortality. Overall mortality rate was 46%. A significant difference in survival was noted in the two support strategies, with VA ECMO patients more likely to survive (p=<0.001). Median ECMO duration among survivors was 69h (IQR 27-167) compared to 290h (IQR 110-535) for those deceased (p=<0.001) Renal, (n=99) mechanical (n=63) and hemorrhagic (n=60) complications were most frequently observed. When stratified by concomitant respiratory diagnosis, a slightly greater degree of survival was seen in patients in ARDS (p=0.005), with higher mortality rates with those with viral influenza (p=0.003) and specifically COVID-19 (p=0.018).
Conclusions: Hospitalized patients with IPF suffer high mortality rates. In the setting of recoverable ARDS or pneumonia, ECMO may be an appropriate strategy for these patients as a bridge to recovery. When ECLS is considered, employing VA rather than VV ECMO may confer a survival benefit.
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