Comparison of extracorporeal membrane oxygenation outcome for influenza-associated acute respiratory failure in Japan between 2009 and 2016

Changing clinical practice and prognosis for severe respiratory failure over time: A nationwide inpatient database study

BACKGROUND

Severe respiratory failure requires numerous interventions and its clinical implementation changes over time. We aimed to clarify the clinical practice and prognosis of severe respiratory failure and its changes over time.

METHODS

In a nationwide Japanese administrative database from 2016 to 2019, we identified nonoperative patients with severe respiratory failure without congestive heart failure as the main diagnosis who received mechanical ventilation (MV) for more than four days. We examined trends in patient characteristics, adjunctive interventions, and prognosis.

RESULTS

Among 66,905 patients included in this study, patients received antibiotics (90%), high-dose corticosteroids (14%), low-dose corticosteroids (18%), and 51% were admitted to the critical care unit. Hospital mortality was 35%. Median mechanical ventilation lasted 10 days. Tracheostomy occurred in 23% of cases. Median critical care and hospital stays were 10 and 25 days, respectively. Among survivors, 23% had mechanical ventilation dependency at hospital discharge. Large relative changes in adjunctive therapies included fentanyl (30%-38%), rocuronium (4.4%-6.7%), vasopressin (3.8%-6.0%), early rehabilitation (27%-38%), extracorporeal membrane oxygenation (0.7%-1.2%), dopamine (15%-10%), and sivelestat (8.6%-3.5%). No notable changes were seen in mechanical ventilation duration, tracheostomy, critical care unit stay, hospital stay, or ventilator dependency at discharge, except for a slight reduction in hospital mortality (36%-34%).

CONCLUSIONS

Several adjunctive therapies for severe respiratory failure changed from 2016 to 2019, with an increase in evidence-based practices and a slight decrease in hospital mortality.

Extracorporeal Membrane Oxygenation Support for Influenza A: Retrospective Review of the Extracorporeal Life Support Organization Registry Comparing H1N1 With Other Subtypes

Supplemental Digital Content is available in the text.

OBJECTIVES:

Although there is a substantial published experience of extracorporeal membrane oxygenation during the H1N1 pandemic, less is known about the use of extracorporeal membrane oxygenation in patients with other subtypes of the influenza A virus. We hypothesized that the severity of illness and survival of patients supported with extracorporeal membrane oxygenation would differ for those with H1N1 influenza A compared with other subtypes of influenza A.

DESIGN, SETTING, PATIENTS:

Retrospective study of extracorporeal membrane oxygenation–supported adults (> 18 yr) with influenza A viral infection reported to the Extracorporeal Life Support Organization Registry between 2009 and 2019. We describe the frequency and compare characteristics and factors associated with in-hospital survival using a least absolute shrinkage and selection operator regression analysis.

MAIN OUTCOMES AND MEASURES:

Of 2,461 patients supported with extracorporeal membrane oxygenation for influenza A, 445 had H1N1, and 2,004 had other subtypes of influenza A. H1N1 was the predominant subtype between 2009 and 2011. H1N1 patients were younger, with more severe illness at extracorporeal membrane oxygenation cannulation and higher reported extracorporeal membrane oxygenation complications than those with other influenza A subtypes. Patient characteristics including younger age and higher weight and patient management characteristics including longer ventilation duration before extracorporeal membrane oxygenation were associated with worse survival. Extracorporeal membrane oxygenation complications were associated with reduced survival. There was no difference in survival to hospital discharge according to influenza subtype after adjusting for other characteristics.

CONCLUSIONS:

Patients supported with extracorporeal membrane oxygenation for H1N1 were younger, with more severe illness than those supported for other influenza A subtypes. Survival to hospital discharge was associated with patient characteristics, management characteristics, and extracorporeal membrane oxygenation complications but was not impacted by the specific influenza A subtype.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Establishment of a Disaster Management-like System for COVID-19 Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation in Japan

The coronavirus disease 2019 (COVID-19) pandemic has increased the number of patients who require extracorporeal membrane oxygenation (ECMO). To manage the demand for ECMO, Japan ECMOnet for COVID-19 was developed as a “disaster management-like system”, utilizing the Cross ICU Searchable Information System (CRISIS) database. This study investigated the effect of the establishment of this disaster management-like system in Japan. This was a nationwide retrospective observational study conducted from 1 February to 31 July in 2020. A total of 187 patients with COVID-19 who received ECMO were included. The median age was 60 years (interquartile range, 53–68), the median length of ventilatory support before ECMO was 3 days (1–5), and the median PaO₂ to FiO₂ ratio at ECMO initiation was 86 (71.3–101.5). During the study period, 165 telephone consultations were conducted, including general questions about ECMO. Among them, 44 concerned patients who were already on ECMO or who ultimately received ECMO. Further coordination, including transport and ECMO physician dispatch, was provided for 23 cases. Overall, 125/187 (66.8%) patients were successfully weaned from ECMO. This study demonstrated that Japan has achieved favorable survival outcomes for patients with COVID-19 who received ECMO with a disaster management-like system. Further research on the causes of these outcomes is needed.

COVID–19呼吸不全に対して3本目のカニューレを用いたVV–V ECMO管理(Role of triple cannulation venovenous extracorporeal membrane oxygenation in patients with coronavirus disease)

A 32–year–old man with dry cough was admitted to a hospital for suspected coronavirus disease–induced pneumonia. The SARS–CoV–2 PCR test showed positive results on day 3 after symptom onset. Mechanical ventilation and venovenous extracorporeal membrane oxygenation (VV ECMO) were initiated for respiratory function deterioration on day 8 after symptom onset. However, ECMO did not maintain adequate oxygenation, and ventilator settings did not allow lung rest. Therefore, secondary ECMO transport was performed, and the patient was transferred to our center via ECMOnet. The reduced oxygenation level was attributed to the use of a small drainage cannula with consequently reduced ECMO circulation. Replacement of the small drainage cannula was unsafe; therefore, an additional drainage cannula was inserted, and the ECMO configuration was switched to VV–V ECMO, which established sufficient ECMO circulation and improved his oxygenation levels, and ventilator settings were modified for lung rest. He was weaned off ECMO on day 14, and retransferred to the previous hospital on day 21 after symptom onset. Selection of a drainage cannula of optimal size is important in patients who receive VV ECMO support. Conversion of a VV ECMO to VV–V ECMO configuration is useful in cases of insufficient ECMO blood flow.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Clinical course of a critically ill patient with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Although several studies have reported on the clinical and epidemiological characteristics of the patient with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), clinical course of the most severe cases requiring treatment in ICU have been insufficiently reported. A 73-year-old man traveling on a cruise ship with history of hypertension and dyslipidemia developed high fever, dyspnea and cough after 7 days of steroid treatment for sudden sensorineural hearing loss, and tested positive for SARS-CoV-2 in sputa polymerase chain reaction (PCR) examination. His respiratory function deteriorated despite treatments with lopinavir/ritonavir, oseltamivir, azithromycin and meropenem at a regional hospital. He was intubated and transferred to the ICU in the tertiary university hospital on day 10 (ICU day 1). Interferon beta-1b subcutaneous injection was initiated immediately to enhance anti-viral therapy, and favipiravir on ICU day 10 upon availability. Progression of organ dysfunctions necessitated inhalation of nitrogen oxide for respiratory dysfunction, noradrenaline for cardiovascular dysfunction and continuous renal replacement therapy for renal dysfunction. His blood samples PCR also tested positive for SARS-CoV-2, indicating viremia, concomitantly with elevated IL-6 levels. VV-ECMO was initiated after sudden exacerbation of respiratory dysfunction on ICU day 7 to maintain oxygenation. The sustained excessive inflammatory cytokines in the present case might have led to the exacerbation of the disease, requiring vigorous organ support therapies to allow for survival and recovery from the rapid progression of multiple organ dysfunctions and severe respiratory failure.

Newly Developed Pediatric Membrane Oxygenator that Suppresses Excessive Pressure Drop in Cardiopulmonary Bypass and Extracorporeal Membrane Oxygenation (ECMO)

This article developes a pediatric membrane oxygenator that is compact, high performance, and highly safe. This novel experimental approach, which imaging the inside of a membrane oxygenator during fluid perfusion using high-power X-ray CT, identifies air and blood retention in the local part of a membrane oxygenator. The cause of excessive pressure drop in a membrane oxygenator, which has been the most serious dysfunction in cardiovascular surgery and extracorporeal membrane oxygenation (ECMO), is the local retention of blood and air inside the oxygenator. Our designed blood flow channel for a membrane oxygenator has a circular channel and minimizes the boundary between laminated parts. The pressure drop in the blood flow channel is reduced, and the maximum gas transfer rates are increased by using this pediatric membrane oxygenator, as compared with the conventional oxygenator. Furthermore, it would be possible to reduce the incidents, which have occurred clinically, due to excessive pressure drop in the blood flow channel of the membrane oxygenator. The membrane oxygenator is said to be the “last stronghold” for patients with COVID-19 receiving ECMO treatment. Accordingly, the specification of our prototype is promising for low weight and pediatric patients.

COVID–19急性呼吸不全への人工呼吸管理とECMO管理：基本的考え方(Mechanical ventilation and extracorporeal membrane oxygenation for acute respiratory failure owing to COVID–19: basic concept)

The pillars of managing critically ill patients with acute respiratory failure owing to coronavirus disease 2019 (COVID–19) are mechanical ventilation and extracorporeal membrane lung oxygenation (ECMO) as supportive therapies for impaired respiratory function. Given the increasing number of patients with COVID–19, a summary of standardized care regarding ECMO that can serve as a reference in clinical practice is proposed as an expert consensus statement. Indications, management practices, and caveats for ECMO management are described, including those in the presence of resource constraints.

Life-threatening antineutrophil cytoplasmic antibody-associated vasculitis after influenza A H1N1 infection requiring veno-venous extracorporeal membrane oxygenation

INTRODUCTION

Antineutrophil cytoplasmic autoantibody-associated vasculitis is an immune-mediated necrotizing vasculitis, affecting small- and medium-sized vessels.

CASE REPORT

A 22-year-old female patient with free medical history presented with life-threatening pulmonary hemorrhage due to antineutrophil cytoplasmic autoantibody-associated vasculitis, temporarily associated with influenza A H1N1 infection. Due to rapidly worsening respiratory failure, despite conventional management, veno-venous peripheral extracorporeal membrane oxygenation was initiated and continued for 26 days, with subsequent renal replacement therapy.

DISCUSSION

We present a case of severe antineutrophil cytoplasmic autoantibody-associated pulmonary vasculitis, managed with veno-venous extracorporeal membrane oxygenation at the initial phase. Despite the significant challenges raised with the use of extracorporeal membrane oxygenation in pulmonary hemorrhage cases, extracorporeal membrane oxygenation may have a significant impact on outcome in this setting, by providing adequate time for a successful immunosuppressive treatment.

Severe influenza: overview in critically ill patients

PURPOSE OF REVIEW

Overview of influenza infection, focusing on outcome and complications in critically ill patients. We also discuss relevant elements in immunopathogenesis and their role as predictors of severity.

RECENT FINDINGS

Pandemic influenza A (H1N1) virus circulates seasonally and remains the predominant subtype among intensive care patients. Mortality in acute respiratory failure (ARF) is around 20%, independent of influenza subtypes. During severe infection, the imbalance between pro-inflammatory and anti-inflammatory molecules, such as Th1 and Th17 cytokines, is associated with complicated infections and mortality. Primary viral pneumonia presents in more than 70% of ICU influenza patients and more than 50% develop acute respiratory distress syndrome. Bacterial secondary infection occurs in 20% of severe cases and Streptococcus pneumoniae and Staphylococcus aureus remain the prevalent pathogens. Myocarditis and late-onset cardiovascular complications are associated with mortality. Antiviral therapy within 48 h after onset, avoidance of corticosteroids and rescue therapies for ARF or myocarditis, such as extracorporeal membrane oxygenation, improve survival.

SUMMARY

The present review summarizes current knowledge on pathogenesis and clinical manifestations of severe influenza. Immunological dysfunction during viral infection correlates with severity and mortality among ICU patients. A theranostics strategy should be implemented to improve outcomes.

Japan ECMOnet for COVID-19. Japan ECMOnet for COVID-19: telephone consultations for cases with severe respiratory failure caused by COVID-19

Recently, the novel coronavirus disease 2019 (COVID-19) started spreading in Japan. Therefore, the number of patients with severe COVID-19 requiring extracorporeal membranous oxygenation (ECMO) is expected to increase. A working group has been formed to provide telephone consultation services for cases with severe respiratory failure caused by COVID-19 in Japan. During the first 13 days of the service, there were 12 consultations. For each consultation, we advised the patient on the initiation of ECMO and arranged transportation for patients with ECMO. Based on experience from the H1N1 influenza pandemic, transporting patients to experienced facilities is essential to obtain better outcomes.

Epidemiology and volume-outcome relationship of extracorporeal membrane oxygenation for respiratory failure in Japan: A retrospective observational study using a national administrative database

Aim

To describe the epidemiology of patients on extracorporeal membrane oxygenation (ECMO) and investigate the possible association between outcomes for respiratory ECMO patients and hospital volume of ECMO treatment for any indications.

Methods

Using data from the Diagnosis Procedure Combination database, a nationwide Japanese inpatient database, between 1 July 2010 and 31 March 2018, we identified inpatients aged ≥18 years who underwent ECMO. Institutional case volume was defined as the mean annual number of ECMO cases; eligible patients were categorized into institutional case volume tertile groups. The primary outcome was in-hospital mortality. For ECMO patients with respiratory failure, the association between institutional case volume group and in-hospital mortality rate was analyzed using a multilevel logistic regression model including multiple imputation.

Results

Extracorporeal membrane oxygenation was carried out on 25,384 patients during the study period; of those, 1,227 cases were for respiratory failure. Respiratory cases were categorized into low- (<8 cases/year), medium- (8-16 cases/year), and high-volume groups (≥17 cases/year). The overall in-hospital mortality rate for respiratory ECMO was 62.5% in low-, 54.7% in medium-, and 50.4% in high-volume institutions. With reference to low-volume institutions, the adjusted odds ratios (95% confidence interval) of the medium- and high-volume institutions for in-hospital mortality were 0.72 (0.50-1.04; P = 0.082) and 0.65 (0.45-0.95; P = 0.024), respectively.

Conclusions

The present study showed that accumulating the experience of using ECMO for any indications could positively affect the outcome of ECMO treatment for respiratory failure, which suggests the effectiveness of consolidating ECMO cases in high-volume centers in Japan.