Among patients receiving extracorporeal membrane oxygenation (ECMO) for cardiopulmonary failure, factors such as ECMO indication, ECMO configuration, and dependence on invasive mechanical ventilation during physical therapy were significantly linked with intensity of early mobilization, according to study results published in the Annals of the American Thoracic Society. In addition, mobilization-related complications were uncommon in physical therapy with femoral cannulation, which may be safe and feasible in this patient population.
Researchers conducted a large, single-center retrospective cohort study of adults who performed active physical therapy while receiving either venovenous or venoarterial ECMO for cardiopulmonary failure to determine the safety and feasibility of mobilization, especially femoral cannulation, which is a common ECMO cannulation approach that is not often included in mobilization literature. The study authors used mixed effects modeling to determine predictors for out-of-bed vs in-bed activity, and also reported adverse events.
The primary outcome was the achievement of any out-of-bed activity, including standing, marching on the spot, or walking, vs only in-bed activity during ECMO support in patients participating in active physical therapy. Secondary outcomes included frequency and intensity of mobilization with femoral cannulation, survival, and discharge disposition.
Of the 511 patients who underwent ECMO at the New York-Presbyterian Hospital/Columbia University Irving Medical Center in New York City between April 1, 2009, and January 31, 2020, 177 patients participated in active physical therapy and were included in the analysis; 124 patients received ECMO as bridge-to-transplantation (BTT) and 53 patients received ECMO as bridge-to-recovery (BTR). The average age among included participants was 44 years, 50% were women, and 60% of participants were non-Hispanic White. Among patients in the BTT group, the most common etiology of respiratory failure was interstitial lung disease (51%), while the most common indication in the BTR group was acute respiratory distress syndrome (ARDS; 60%). Compared with the BTT group, the BTR group had significantly higher illness scores and received invasive mechanical ventilation prior to ECMO initiation more frequently.
There were 2706 active physical therapy sessions reported in the 177 patients, 138 of whom achieved out-of-bed activity; 108 patients ambulated (1284 sessions) and 34 of these patients had femoral cannulae (250 sessions).
A BTT status, venovenous ECMO, later cannulation year, and a higher Charlson Comorbidity Index was all linked with an increased odds of achieving out-of-bed compared with in-bed physical therapy (odds ratios [ORs]: 17.2, 2.83, 1.65, 1.53, respectively). Conversely, invasive mechanical ventilation (OR, 0.11) and femoral cannulation (OR, 0.19) were linked with a decrease in the odds of out-of-bed physical therapy.
A total of 59 adverse events in 28 patients were directly attributable to their physical therapy sessions. Of the participants, 107 survived to hospital discharge: 67 patients in the BTT group and 40 in the BTR group. Of the survivors, 97% were either discharged home or to an acute rehabilitation center.
“Mobilization with femoral cannulation, including ambulation, was safe and feasible, and due to ease of placement, femoral cannulation may be a reasonable initial strategy in centers with sufficient expertise and training,” the researchers concluded.
Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.
Abrams D, Madahar P, Eckhardt CM, et al. Early mobilization during ECMO for cardiopulmonary failure in adults: factors associated with intensity of treatment. Ann Am Thorac Soc. Published online June 2, 2021. doi:10.1513/AnnalsATS.202102-151OC