Extracorporeal membrane oxygenation (ECMO) rescue for unanticipated failed airway management - Fact or Fiction?

Extracorporeal membrane oxygenation (ECMO) can provide elective or standby support for oxygenation and ventilation during apnoea for complex airway surgery or severe airway obstruction where conventional ventilation with a tracheal tube is impossible. Both elective and standby ECMO require the placement of a large cannula in major vessels, as well as the presence of a perfusionist, specialised equipment, and experienced personnel. Most hospitals do not have an ECMO service, and even in those that do, it is unrealistic to expect the establishment of ‘Rescue ECMO’ with no prior set-up following failed tracheal intubation and failed oxygenation within a few minutes before irreversible brain and organ damage occurs. In our experience during elective and standby ECMO for airway surgery, it takes at least 15–20 min to place a large cannula and confirm ECMO. It seems inconceivable to institute ‘rescue ECMO’ without preparation within a few minutes. The Fourth National Audit Project study concluded that complication and mortality rates are high due to delays in predicting, diagnosing, and providing definitive treatment for difficult airways.[1] Mortality and morbidity related to airway management can often be prevented in most cases by planning a strategy. An improvement for the recent airway management guidelines was the recommendation for the use of ECMO. The Canadian Airway Focus Group’s updated consensus for the management of difficult airways stated that even in an experienced team, establishing ECMO may be complicated and time-consuming.[2] ‘Rescue ECMO’ has no role as a rescue technique for an unanticipated failed airway encountered after the induction of general anaesthesia. The American Society of Anesthesiologists (ASA) practice guideline for difficult airway management mentions reports of the successful use of ECMO.[3] In the algorithms, ECMO is suggested as an invasive technique for both anticipated, unanticipated, and emergency difficult airway management, to be considered as a last resort. Recently, the European Society of Anaesthesiology and Intensive Care, along with the British Journal of Anaesthesia, jointly recommended ECMO as one of the invasive techniques for managing failed tracheal intubation in neonates and infants.[4] This guideline states that we can consider ECMO as a rescue intervention when equipment is available. This means that in a critical situation requiring an urgent invasive approach, such as cannot intubate cannot oxygenate (CICO), the recommendation is to initiate ECMO if the specified invasive technique fails or is not feasible. However, ECMO is a complex and time-intensive intervention that requires a coordinated decision from a dedicated multidisciplinary team. The optimal position of the outflow and inflow cannulas should be confirmed. Blood access should be discussed before the procedure to ensure optimal patient safety and minimise potential complications.[5] ‘Rescue ECMO’ cannot technically serve as a rescue method for a failed airway. The current literature on ECMO use in high-risk airway surgery is primarily based on case reports and small case series conducted in children and infants. Studies on extracorporeal cardiopulmonary resuscitation provide us with more detailed information in this regard. In a retrospective analysis of 171 out-of-hospital cardiac arrest patients, it has been reported that the minimum time from collapse to venoarterial ECMO (VA-ECMO) was 69 min, and this period could extend to 98 min.[6] In an Australian metropolitan setting with experienced team members, the mean time from emergency call to ECMO initiation was 50 min.[7] The mean time from decision to ECMO support was 16 min. However, these were patients with ongoing, uninterrupted chest compressions. These periods are not acceptable in a CICO patient with a high risk of hypoxic brain injury.[8] In conclusion, both the ASA and the joint guidelines from the European Society of Anaesthesiology and Intensive Care, as well as the British Journal of Anaesthesia, include ECMO as a step in the algorithm for managing failed intubation and oxygenation in neonates and infants. Elective and standby ECMO can be a safe pre-emptive alternative plan for managing an impossible airway, as anticipated in the Canadian Airway Focus Group guidelines. ‘Rescue ECMO’ in an unanticipated CICO scenario with no planning, equipment, or personnel is unrealistic and should not be considered as an option.

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