• Tuberculosis and Respiratory Diseases
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• v.72 no.1
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• pp.1-7
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• 2012

Extracorporeal Membrane Oxygenation (ECMO) support to tissue oxygenation has been shown to improve survival in patients with life threatening respiratory distress syndrome or cardiac failure. Extracorporeal life support such as ECMO, including extracorporeal $CO_2$ removal ($ECCO_2R$), is used as temporary support until successful recovery of organs. A recently published multicentre randomized controlled trial, known as the CESAR (conventional ventilation or extracorporeal membrane oxygenation for severe adult respiratory failure) trial, was the first trial to demonstrate the utility of ECMO in acute respiratory distress syndrome (ARDS). During the 2009 influenza A (H1N1) pandemic, there were many reports of patients with severe ARDS related to H1N1 infection treated with ECMO. These reports revealed a high survival rate and effectiveness of ECMO. In this review, we explain the indication of ECMO clinical application, the practical types of ECMO, and complications associated with ECMO. In addition, we explain recent new ECMO technology and management of patients during ECMO support.

• Tuberculosis and Respiratory Diseases
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• v.40 no.2
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• pp.91-97
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• 1993

Pulmonary surfactant is a lipoprotein complex composed primarily of phospholipid and lung specific apoproteins that reduces surface tension in the alveolus and maintains alveolar stability at low lung volume. Adult respiratory distress syndrome still carries a very high morbidity and mortality. The surfactant system is vital to the maintenance of proper lung function, any type of surfactant deficiency, whether primary or secondary, will contribute significantly to the development of pulmonary pathophysiology. Various mechanisms in adult respiratory distress syndrome may be responsible for such alterations in the surfactant system. Surfactant replacement is now an established treatment for neonatal respiratory distress syndrome, reducing both incidence of complications and mortality. With the current knowledge of surfactant physiology and the pathophysiology of the adult respiratory distress syndrome exogenous surfactant treatment or stimulation of endogenous surfactant synthesis and secretion will prove to be beneficial in preventing and treating the adult respiratory distress syndrome. The study of clinical surfactant therapy for adult respiratory distress syndrome is just beginnig and this can be viewed as an area with exciting potential. As soon as surfactant preparations become more widely available trials should begin to define the role of surfactant treatment in the adult respiratory distress syndrome as an adjunct to available treatment techniques.

• Tuberculosis and Respiratory Diseases
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• v.79 no.3
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• pp.188-192
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• 2016

Antisynthetase syndrome has been recognized as an important cause of autoimmune inflammatory myopathy in a subset of patients with polymyositis and dermatomyositis. It is associated with serum antibody to aminoacyl-transfer RNA synthetases and is characterized by a constellation of manifestations, including fever, myositis, interstitial lung disease, mechanic's hand-like cutaneous involvement, Raynaud phenomenon, and polyarthritis. Lung disease is the presenting feature in 50% of the cases. We report a case of a 60-year-old female with acute respiratory distress syndrome (ARDS), which later proved to be an unexpected and initial manifestation of anti-Jo-1 antibody-positive antisynthetase syndrome. The present case showed resolution of ARDS after treatment with high-dose corticosteroids. Given that steroids are not greatly beneficial in the treatment of ARDS, it is likely that the improvement of the respiratory symptoms in this patient also resulted from the prompt suppression of the inflammatory systemic response by corticosteroids.

• Journal of Chest Surgery
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• v.54 no.1
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• pp.36-44
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• 2021

Background: Extracorporeal membrane oxygenation (ECMO) has become increasingly accepted as a life-saving procedure for patients with severe acute respiratory distress syndrome (ARDS). This study investigated the relationship between cumulative fluid balance (CFB) and outcomes in adult ARDS patients treated with ECMO. Methods: We retrospectively analyzed the data of adult ARDS patients who received ECMO between December 2009 and December 2019 at Korea University Anam Hospital. CFB was calculated during the first 7 days after ECMO initiation. The primary endpoint was 28-day mortality. Results: The 74 patients were divided into survivor (n=33) and non-survivor (n=41) groups based on 28-day survival. Non-survivors showed a significantly higher CFB at 1-7 days (p<0.05). Cox multivariable proportional hazard regression revealed a relationship between CFB on day 3 and 28-day mortality (hazard ratio, 3.366; 95% confidence interval, 1.528-7.417; p=0.003). Conclusion: In adult ARDS patients treated with ECMO, a higher positive CFB on day 3 was associated with increased 28-day mortality. Based on our findings, we suggest a restrictive fluid strategy in ARDS patients treated with ECMO. CFB may be a useful predictor of survival in ARDS patients treated with ECMO.

• Journal of Trauma and Injury
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• v.32 no.3
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• pp.136-142
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• 2019

Purpose: Near drowning refers to immediate survival after asphyxia due to submersion or immersion in water, which is a crucial public safety problem worldwide. Acute lung injury or acute respiratory distress syndrome (ARDS) is a common complication of near drowning. The purpose of this study was to investigate the feasibility and effectiveness of noninvasive nasal positive pressure ventilation (NINPPV). Methods: This retrospective study was conducted at a tertiary emergency department. NINPPV was administered for moderate ARDS caused by submersion or immersion in patients who were older than 18 years, from January 2015 to December 2018. We collected the demographic (age, sex, length of hospital stay, and outcome), laboratory (arterial blood gas, lactate, oxygen saturation, partial pressure of oxygen divided by the fraction of inspired oxygen, complete blood count, blood urea nitrogen, and creatinine), and clinical data (acute lung injury index and ventilator failure) of the patients. A statistical analysis was performed using Statistical Package for the Social Sciences version 20.0 for Windows. Results: NINPPV treatment was provided to 57 patients for near drowning, 45 of whom (78.9%) were successfully treated without complications; in 12 (21.1%), treatment was changed to invasive mechanical ventilation within 48 hours due to ARDS or acute kidney injury. NINPPV treatment was successful in 31 (75.6%) out of 41 sea-water near drowning patients. They were more difficult to treat with NINPPV compared with the fresh-water near drowning patients (p<0.05). Conclusions: NINPPV would be useful and feasible as the initial treatment of moderate ARDS caused by near drowning.

• Tuberculosis and Respiratory Diseases
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• v.69 no.2
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• pp.75-80
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• 2010

The year of 2009~2010 brought a number of concepts and new ideas were evaluated with promising results. However, some studies that challenged many beliefs. In acute respiratory distress syndrome (ARDS), recent clinical studies took into consideration of pathophysiologic changes of respiratory system compliance. Meta-analysis of positive end-expiratory pressure trials showed survival benefit of high positive end-expiratory pressure in ARDS. Until now, prone positioning did not show survival benefit in patients with ARDS. Extracorporeal membrane oxygenation (ECMO) based management improved survival in patients with severe ARDS. ECMO can be a management option in severe ARDS. Sedation is a standard practice in critically ill patients needing mechanical ventilation. However, Danish group reported less sedation of critically ill patients receiving mechanical ventilation was associated with an increase in days without ventilation. Although this single center study has some limitations, the overall results are promising. Use of maximal sterile barrier precautions (mask, sterile gown, sterile gloves, and large sterile drapes) with chlorhexidine-impregnated dressing reduced central venous catheter related infection. Selective oropharyngeal decontamination (application of topical antibiotics in the oropharynx) reduced the mortality rate of an intensive care unit (ICU) population. Normoglycemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial reported intensive glucose control increased mortality among adults in the ICU. Some of the results of above papers are promising. However, some ideas may need for more frequent individual assessment and increase the workload of ICU staffs. Before implementation of new practice in ICU, we should take into consideration of individual hospital situation including human and material resources.

• Tuberculosis and Respiratory Diseases
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• v.79 no.4
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• pp.214-233
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• 2016

There is no well-stated practical guideline for mechanically ventilated patients with or without acute respiratory distress syndrome (ARDS). We generate strong (1) and weak (2) grade of recommendations based on high (A), moderate (B) and low (C) grade in the quality of evidence. In patients with ARDS, we recommend low tidal volume ventilation (1A) and prone position if it is not contraindicated (1B) to reduce their mortality. However, we did not support high-frequency oscillatory ventilation (1B) and inhaled nitric oxide (1A) as a standard treatment. We also suggest high positive end-expiratory pressure (2B), extracorporeal membrane oxygenation as a rescue therapy (2C), and neuromuscular blockage for 48 hours after starting mechanical ventilation (2B). The application of recruitment maneuver may reduce mortality (2B), however, the use of systemic steroids cannot reduce mortality (2B). In mechanically ventilated patients, we recommend light sedation (1B) and low tidal volume even without ARDS (1B) and suggest lung protective ventilation strategy during the operation to lower the incidence of lung complications including ARDS (2B). Early tracheostomy in mechanically ventilated patients can be performed only in limited patients (2A). In conclusion, of 12 recommendations, nine were in the management of ARDS, and three for mechanically ventilated patients.

• Tuberculosis and Respiratory Diseases
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• v.80 no.3
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• pp.296-303
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• 2017

Background: Acute respiratory distress syndrome (ARDS) is related to high mortality and morbidity. There are no proven therapeutic measures however, to improve the clinical course of ARDS, except using low tidal volume ventilation. Metformin is known to have pleiotropic effects including anti-inflammatory activity. We hypothesized that pre-admission metformin might alter the progress of ARDS among intensive care unit (ICU) patients with diabetes mellitus (DM). Methods: We performed a retrospective cohort study from January 1, 2005, to April 30, 2005 of patients who were admitted to the medical ICU at Seoul National University Hospital because of ARDS, and reviewed ARDS patients with DM. Metformin use was defined as prescribed within 3-month pre-admission. Results: Of 558 patients diagnosed with ARDS, 128 (23.3%) patients had diabetes and 33 patients were treated with metformin monotherapy or in combination with other antidiabetic medications. Demographic characteristics, cause of ARDS, and comorbid conditions (except chronic kidney disease) were not different between metformin users and nonusers. Several severity indexes of ARDS were similar in both groups. The 30-day mortality was 42.42% in metformin users and 55.32% in metformin nonusers. On multivariable regression analysis, use of metformin was not significantly related to a reduced 30-day mortality (adjusted ${\beta}-coefficient$, -0.19; 95% confidence interval, -1.76 to 1.39; p=0.816). Propensity score-matched analyses showed similar results. Conclusion: Pre-admission metformin use was not associated with reduced 30-day mortality among ARDS patients with DM in our medical ICU.

• Parasites, Hosts and Diseases
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• v.51 no.5
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• pp.551-555
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• 2013

Complicated malaria is mainly caused by Plasmodium falciparum, but, increasingly, Plasmodium vivax is also being reported as a cause. Since the reemergence of indigenous vivax malaria in 1993, cases of severe malaria have been steadily reported in Korea. Herein, we report a case of vivax malaria complicated by adult respiratory distress syndrome (ARDS) that was successfully managed with extracorporeal membrane oxygenation (ECMO). A 59-year-old man presented at our hospital with fever and abdominal pain, which had persisted for 10 days. On admission, the patient had impaired consciousness, shock, hypoxia and haziness in both lungs, jaundice, thrombocytopenia and disseminated intravascular coagulation, metabolic acidosis, and acute kidney injury. A peripheral blood smear and a rapid diagnostic test verified P. vivax mono-infection. Ten hours after admission, hypoxia became more severe, despite providing maximal ventilatory support. The administration of antimalarial agents, ECMO, and continuous venovenous hemofiltration resulted in an improvement of his vital signs and laboratory findings. He was discharged from the hospital 7 weeks later, without any sequelae.

• Tuberculosis and Respiratory Diseases
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• v.82 no.3
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• pp.251-260
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• 2019

Background: Beyond its current function as a rescue therapy in acute respiratory distress syndrome (ARDS), extracorporeal membrane oxygenation (ECMO) may be applied in ARDS patients with less severe hypoxemia to facilitate lung protective ventilation. The purpose of this study was to evaluate the efficacy of extended ECMO use in ARDS patients. Methods: This study reviewed 223 adult patients who had been admitted to the intensive care units of 11 hospitals in Korea and subsequently treated using ECMO. Among them, the 62 who required ECMO for ARDS were analyzed. The patients were divided into two groups according to pre-ECMO arterial blood gas: an extended group (n=14) and a conventional group (n=48). Results: Baseline characteristics were not different between the groups. The median arterial carbon dioxide tension/fraction of inspired oxygen ($FiO_2$) ratio was higher (97 vs. 61, p<0.001) while the median $FiO_2$ was lower (0.8 vs. 1.0, p<0.001) in the extended compared to the conventional group. The 60-day mortality was 21% in the extended group and 54% in the conventional group (p=0.03). Multivariate analysis indicated that the extended use of ECMO was independently associated with reduced 60-day mortality (odds ratio, 0.10; 95% confidence interval, 0.02-0.64; p=0.02). Lower median peak inspiratory pressure and median dynamic driving pressure were observed in the extended group 24 hours after ECMO support. Conclusion: Extended indications of ECMO implementation coupled with protective ventilator settings may improve the clinical outcome of patients with ARDS.