Extracorporeal Ventilatory Therapies

Clinical use of extracorporeal ventilatory support technologies is increasing exponentially with an expanding range of indications for patients with cardiopulmonary disease. Rapid adoption is occurring despite limited basic and translational research on extracorporeal support and only a handful of large-scale multicenter trials to inform clinical practice. At present, clinicians must rely on pathophysiologic reasoning and understanding of device technology to guide the initiation, titration, and weaning of support. Expanding deployment of extracorporeal devices has also led to an evolution in the methods used to initiate support. From its early role as an extension of the cardiopulmonary bypass circuit, in which support was initiated in the operating room for patients unable to wean from bypass following cardiotomy, extracorporeal support is increasingly a component of advanced critical care and is available for bedside deployment in intensive care units at tertiary medical centers. As support expands to new indications and different patient populations, cannulation of peripheral vessels has also expanded to include not only surgical vascular cutdowns but also percutaneous methods more common to the intensivist. The use of extracorporeal ventilatory therapies to provide circulatory support, including in cases of active cardiopulmonary arrest, further fuels demand for clinicians to become familiar with the management and physiologic effects of these new devices. This chapter reviews the development of extracorporeal ventilatory therapies and details their implementation and management in supporting patients with respiratory and circulatory failure.