Background

• Extracorporeal Membrane Oxygenation (ECMO) is used as a temporary life support in patients with end stage pulmonary and/or cardiac failure. Due to the limited number of organs available for children, ECMO can be used as a method to extend the life of a suitable candidate allowing them more time on the transplant list.
• Historically, ECMO was the strongest negative predictor of one-year survival post-lung transplant with a major contributing factor being secondary complications associated with prolonged immobility and bed rest. With advances in technology, awake and ambulatory ECMO is now a feasible option.
• Two main types of ECMO:
  • Veno-Venous (VV) ECMO                               Veno-Arterial (VA) ECMO

Case Scenario & PICO

Case: 10-year old female admitted to the hospital secondary to CF exacerbation. Conditioned continued to worsen until she reached respiratory failure and was placed on mechanical ventilation. Despite FiO2 at 100%, patient remained hypercapnic and hypoxic resulting in medical sedation and implementation of VV-ECMO. Patient was placed on the urgent bilateral lung transplant (BLTx) list.

PICO: Do pediatric patients awaiting a lung transplant (LTx) have improved functional outcomes and reduced hospital length of stay if they receive ambulatory ECMO as a bridge to LTx compared to those who receive traditional non-ambulatory ECMO?

Search Strategy

Databases Searched: PubMed, CINAHL, OAIster

Inclusion Criteria: English language, Human subjects, All age groups, Ambulatory ECMO, ECMO as a bridge to heart and/or lung transplant

Exclusion Criteria: Clinical Commentary/Narrative Review, Duplicate in Systematic Review, Non-ambulatory ECMO, Intervention focused on post-transplant ambulatory ECMO, Ambulatory ECMO awaiting a non-lung transplant.

Results

Limitations

• Low quality evidence
• Small sample sizes
• Time and type of PT interventions varied across studies

Clinical Bottom Line

• There is limited, low quality evidence that suggests that ambulatory ECMO improves functional outcomes and reduces hospital LOS in pediatric patients awaiting a lung transplant.
• Ambulatory ECMO is complex and high-risk and should only be performed within a multidisciplinary team in hospitals with ample experience to ensure optimal safety.

Application to Case

• Initiate the conversation with the medical team regarding the benefits associated with immediate PT following ECMO initiation. It will be a multidisciplinary team effort to provide active rehabilitation while on ECMO in order to guarantee safety.
• POC: Initiate PT immediately following initiation of ECMO progressing from PROM while patient is weaning off medical sedation (avoiding ROM of affected limb) –> active exercises in bed –> resistance exercises –> task specific exercises including ambulation until organ transplant.

Acknowledgments

Richard Lauer, PhD and TU DPT class of 2017

References

1. Bain JC, Turner DA, Rehder KJ, et al. Economic outcomes of extracorporeal membrane oxygenation with and without ambulation as a bridge to lung transplantation. Respir Care. 2016;61(1):1-7. doi: 10.4187/respcare.03729 [doi].

2. Hayes D,Jr, Galantowicz M, Preston TJ, Lloyd EA, Tobias JD, McConnell PI. Tracheostomy in adolescent patients bridged to lung transplantation with ambulatory venovenous extracorporeal membrane oxygenation. J Artif Organs. 2014;17(1):103-105. doi: 10.1007/s10047-013-0738-9 [doi].

3. Lowman JD, Kirk TK, Clark DE. Physical therapy management of a patient on portable extracorporeal membrane oxygenation as a bridge to lung transplantation: A case report. Cardiopulm Phys Ther J. 2012;23(1):30-35.

4. Polastri M, Loforte A, Dell’Amore A, Nava S. Physiotherapy for patients on awake extracorporeal membrane oxygenation: A systematic review. Physiother Res Int. 2015. doi: 10.1002/pri.1644 [doi].

5. Wong JY, Buchholz H, Ryerson L, et al. Successful semi-ambulatory veno-arterial extracorporeal membrane oxygenation bridge to heart-lung transplantation in a very small child. Am J Transplant. 2015;15(8):2256-2260. doi: 10.1111/ajt.13239 [doi].

VV-ECMO and VA-ECMO Pictures: http://tele.med.ru/book/cardiac_anesthesia/text/gr/gr031.htm

By: Erika Shumock, SPT