Severe Respiratory Failure and ECMO

There are 5 centres in England commissioned to offer ECMO for severe acute respiratory failure in adults. These are:

Guy's and St Thomas' Hospital NHS FT

Papworth Hospital NHS FT

University Hospitals of Leicester NHS Trust

University Hospital of South Manchester NHS FT

The ECMO Transfer pathway film is now available

Each of the centres cover a defined geographical area (see picture below) and a number of established critical care networks that exist.This ensures that any patient that requires critical care services are able to access them.

Referral
All patient referrals for Severe Respiratory Failure and/or ECMO in the NWLCC Network should be made DIRECT to the Royal Brompton Hospital.

Referrals - are now being done online here

If you wish to refer a patient for ECMO please complete the referral on the pathway and then contact the ECMO Retrieval Team on 020 7351 8585
The ECMO team will be notified of your online referral and will be expecting your callThe online referral is in 2 stages and there are videos on the pathway to assist you with this process.

Through completing the online referral:

You will provide the ECMO team with more robust and rigorous information about your patient, allowing clear and appropriate decisions to be made.
The whole team surrounding the patient is able to register and link to the patient to see the information and advice given. Guidance on how to do this is in the videos.
The pathway also allows you to log on and see how your patient is doing whilst they are at Royal Brompton
You will be able to view information about the patient when they are ready for repatriation back to you, which will allow you to prepare your multidisciplinary team.

Assistance and advice available at the Royal Brompton includes imaging reviews (sent via CD, IEP, or bbRad), thoracic surgical input, extracorporeal carbon dioxide removal and ECMO support.

Advice should be obtained sooner rather than later for patients in whom adequate arterial blood gases cannot be achieved using lung protective tidal volumes and pressures.

The potential survival benefits of ECMO as a lung protective strategy diminish sharply after one week of conventional ventilation at high pressure and high inspired oxygen concentration.

Typical Patients: will include those with reversible disease associated with one or more of:

Severe hypoxaemia (e.g. PaO₂/FiO₂ < 13.3kPa)
Severe hypercapnic acidosis (e.g. pH<7.20)
Inability to achieve lung protective tidal volumes and pressures (tidal volume < 6 mL/Kg predicted body weight, plateau pressure < 30 cmH₂O)
Failure to improve with rescue therapies e.g. high frequency oscillation and prone positioning
Significant air leak/bronchopleural fistula

Retrieval: A “consultant-delivered” retrieval service (including mobile ECMO) is available from the Royal Brompton Hospital 24/7. Specific transfer equipment is available which the team will bring with them.

Referring hospital: If ECMO is to be instituted at the referring hospital, the ECMO retrieval team will need access to an operating theatre, anaesthetist, scrub nurse, radiographer with image intensifier, and 2 units of blood. The patient’s relatives should be asked to be available for discussion about retrieval and extracorporeal support.

ECMO centre coordination: In the event that the Royal Brompton cannot take a patient who is considered appropriate for ECMO, the Royal Brompton will coordinate onward referral to another designated centre. All five designated ECMO centres (Royal Brompton, GSTT, Papworth, Glenfield, and Wythenshawe) will work in this way to manage referrals and capacity.

Step-down and repatriation: Generally, patients will not be repatriated to the referring hospital until it is clear that they are very unlikely to need further escalation of respiratory support.Repatriation to the referring site will be carried out by the Royal Brompton transfer team.