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Commentary |

Ambulatory Extracorporeal Membrane Oxygenation as a Bridge to Lung TransplantationAmbulatory Extracorporeal Membrane Oxygenation: Walking While Waiting FREE TO VIEW

Carli J. Lehr, MD; David W. Zaas, MD, MBA; Ira M. Cheifetz, MD; David A. Turner, MD
Author and Funding Information

From the Division of Pulmonary and Critical Care (Dr Lehr), Department of Internal Medicine, Duke University Hospital and Health System; Duke Raleigh Hospital (Dr Zaas); and the Division of Pediatric Critical Care Medicine (Drs Cheifetz and Turner), Department of Pediatrics, Duke Children’s Hospital, Durham, NC.

CORRESPONDENCE TO: David A. Turner, MD, Pediatric Critical Care, DUMC Box 3046, Durham, NC 27710; e-mail: david.turner@dm.duke.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(5):1213-1218. doi:10.1378/chest.14-2188
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The proportion of critically ill patients awaiting lung transplantation has increased since the implementation of the Lung Allocation Score (LAS) in 2005. Critically ill patients comprise a sizable proportion of wait-list mortality and are known to experience increased posttransplant complications. These critically ill patients have been successfully bridged to lung transplantation with extracorporeal membrane oxygenation (ECMO), but historically these patients have required excessive sedation, been immobile, and have had difficult functional recovery in the posttransplant period and high mortality. One solution to the deconditioning often seen in critically ill patients is the implementation of rehabilitation and ambulation while awaiting transplantation on ECMO. Ambulatory ECMO programs of this nature have been developed in an attempt to provide rehabilitation, physical therapy, and minimization of sedation prior to lung transplantation to improve both surgical and posttransplant outcomes. Favorable outcomes have been reported using this novel approach, but how and where this strategy should be implemented remain unclear. In this commentary, we review the currently available literature for ambulation and rehabilitation during ECMO support as a bridge to lung transplantation, discuss future directions for this technology, and address the important issues of resource allocation and regionalization of care as they relate to ambulatory ECMO.

More than 3,000 lung transplants are performed annually, and > 2,000 patients were added to the transplant list in the past year alone.1,2 Since implementation of the Lung Allocation Score (LAS) in 2005, patients awaiting lung transplantation have continued to exhibit increased disease severity, a persistently high mean wait-list mortality of 15.7%, and a mean national waiting time of 3.6 months.2 Postimplementation of LAS, critically ill patients are more likely to be considered for transplant, and those critically ill patients who are unable to receive a lung transplant comprise approximately 10% of waitlist deaths.2 In addition, critically ill patients have a significantly increased incidence of posttransplant complications.3,4

In the subset of patients requiring mechanical ventilation prior to lung transplantation, there is a significant decrease in 1-year survival from 80% to 63.7%, with a relative risk of death in the first year posttransplant of 1.57 (95% CI, 1.31-1.88).3 Most critically ill patients on the transplant waiting list have prolonged pre- and posttransplant ICU stays, difficulty liberating from mechanical ventilation, poor wound healing, increased incidence of infection, poor nutrition, and decreased muscle mass and functional status, all of which may contribute to postoperative morbidity and mortality.3,4

As patients on the lung transplant waiting list develop critical illness, clinicians are faced with the unique challenge of attempting to minimize ICU-related complications while supporting them prior to transplantation. To support the most critically ill patients, extracorporeal membrane oxygenation (ECMO) may be implemented to eliminate some of the complications related to prolonged mechanical ventilation.57 Although use of ECMO is increasing in patients who exhibit severe respiratory failure, traditional ECMO management has been associated with high-dose sedation and immobilization resulting in critical illness myopathy. Outcomes using ECMO as a bridge to transplantation were traditionally poor, with an average 1-year survival of approximately 40%.815

Historically, the early experience of many centers with ECMO was discouraging, with many small case studies demonstrating mixed results regarding the clinical usefulness of ECMO as a bridge to transplantation. The first case of ECMO as a bridge to transplantation occurred in 1975, followed by a small number of patients who died on the waiting list.16 ECMO use declined following a randomized controlled trial published in TheJournal of the American Medical Association in 1979 that demonstrated poor outcomes.17 ECMO use then gradually increased over the following decade and into the early 1990s, with sporadic reports of successful bridging of patients to transplantation.8

In the past 2 decades, there have been an increasing number of small case reports and series describing patients being successfully bridged to lung transplantation with ECMO; however, outcomes remained well below those of noncritically ill transplant recipients.8,9,1315 An analysis performed by Jackson et al15 in 2008 combined patients from small case studies using ECMO as a bridge to transplantation and estimated a 12-month survival of 50%, compared with the then-benchmark survival of 78%.18 A study published in 2010 by Nosotti et al11 demonstrated similar results, with additional morbidities of psychologic disorders and critical illness myopathy in surviving patients.15

Despite these historical outcomes, reports suggest that an awake approach to ECMO may allow critically ill patients to achieve more successful transplant outcomes.5,7,19 Of the 18 patients reported by Javidfar et al20 with acute respiratory failure who were supported with traditional ECMO, 10 patients successfully underwent transplantation. A novel study performed by Fuehner et al7 demonstrated that 23 patients supported with awake ECMO compared with 34 control patients supported with invasive mechanical ventilation had significantly increased 6-month posttransplant survival (80% vs 50%, P = .02). Positive outcomes with awake ECMO were also demonstrated by Nosotti et al5 in a study that demonstrated seven of 11 patients undergoing awake ECMO with minimal sedation and cycles of noninvasive ventilation had a marked improvement in 1-year survival of 85.7% compared with 50% in the traditional invasive mechanical ventilation group. ECMO has the potential to provide a unique bridging strategy for critically ill patients awaiting lung transplantation, supporting their oxygenation needs while minimizing complications associated with invasive mechanical ventilation. Our center and others have taken this awake ECMO strategy one step further by including active rehabilitation and ambulation of patients receiving ECMO as a bridge to lung transplantation.6,2124

Rehabilitation and ambulation on ECMO in this manner is a complex undertaking involving a notably different approach to sedation and mobility relative to traditional ECMO. As described in detail elsewhere, this novel approach requires engagement and involvement of the entire multidisciplinary team, including physical therapists, nurses, respiratory therapists, ECMO specialists, and physicians.6,21 An example of a typical rehabilitation protocol includes bid physical therapy sessions with additional independent sessions as tolerated by the patient. Physical therapy sessions usually begin with supine strengthening and conditioning exercises (eg, range of motion activities and stretching), progressing to exercises performed in the sitting position to strengthen the torso, upper extremities, and lower extremities, and result in standing and ambulation. The goal of the program is to progress to walking as quickly as possible. Depending on the clinical circumstances and degree of deconditioning prior to cannulation, some patients ambulate on the first day of ECMO. To continue to promote rehabilitation prior to lung transplant, these patients then walk once or twice daily for as much distance as tolerated.6,21

The ambulatory ECMO experience as described in our center and others has provided a promising advancement of ECMO as a bridge to transplantation.6,21,22,24 As programs become more comfortable with managing more awake and ambulatory patients receiving ECMO, it is likely that this innovative strategy may be extended to other critically ill patients who are supported with ECMO. Although the potential benefit of an awake and ambulatory ECMO strategy for patients bridged to lung transplantation is multifactorial, it is likely this approach may help further mitigate critical illness myopathy, a key source of morbidity in patients in the ICU.

Critical illness myopathy is pervasive in the ICU, with a prospective study demonstrating nearly 30% of patients meeting criteria for critical illness myopathy and polyneuropathy.25,26 A similar investigation demonstrated > 25% of patients who were placed on mechanical ventilation for > 7 days had evidence of ICU-acquired weakness.25,26 Early mobility protocols and interruption of sedation in patients in the ICU are becoming commonplace, with notably improved outcomes, including less delirium, increased ventilator-free days, and shortened length of stay.2729 The practice of rehabilitation in patients on ECMO is consistent with this movement toward early mobilization and has been shown to be safe in multiple studies.6,2224

In patients receiving transplant specifically, this approach of active rehabilitation during ECMO support represents a novel approach to addressing pretransplant conditioning, which is a major predictor of morbidity and mortality.12,30 Minimizing the deconditioning that has traditionally been common in critically ill patients requiring invasive mechanical ventilation, ECMO, or both, with its associated sedation, immobilization, and potentially multiple cannulation sites, is an important priority.3 Awake and ambulatory ECMO protocols have fundamentally changed the manner in which sedation is administered to patients on ECMO in many ICUs.2224 In our center, our protocol of awake, ambulatory ECMO has been successfully implemented in both pediatric and adult patients with multiple comorbidities, including bacteremia, diabetes, and malnutrition.

As technology and innovation continue to expand the ability to support patients during episodes of critical illness, programs focusing on ambulatory ECMO provide a valuable tool for patients to hasten recovery by minimizing sedation, bed rest, and barotrauma associated with prolonged invasive mechanical ventilation. With each successful bridge to transplant, ambulatory programs continue to refine strategies to make the program safer and more efficient with improved use of limited resources. It is our hope to continue to expand programs and integrate ambulatory ECMO into the repertoire of intensive care physicians and trainees as they care for the most critically ill patients.

Programs with the ability to offer ambulatory ECMO have the potential to provide an opportunity for successful lung transplantation and survival in patients who would have otherwise died. To our knowledge, there are only a few transplant centers that routinely offer ambulatory ECMO as a bridge to lung transplantation, but the number of centers attempting ambulatory ECMO is increasing. However, the development of an ambulatory ECMO program is a complex undertaking.6,21 It can be particularly challenging for institutions with lower volumes of critically ill patients prior to transplantation or those in which the support staff does not have experience with the practice of ambulating critically ill patients. Of note, this ambulatory ECMO approach has been successfully undertaken both for patients who deteriorate while already listed for transplant and those with irreversible lung injury who decompensate and are then listed following ECMO cannulation.6,2124

Based on our center’s experience with ambulatory ECMO, in a study performed by Rehder et al,21 patients had shorter mean posttransplant length of mechanical ventilation, ICU, and hospital stay, and promising survival data (100% survival for patients who are 1 year posttransplant, and one patient alive at 4 months posttransplant). The rehabilitation protocol implemented in those patients is outlined in depth by Turner et al6; it culminates in patients walking while being maintained on ECMO. In patients who underwent ambulatory ECMO, the mean time to hospital discharge, as well as time to posttransplant hospital discharge, were comparable to those patients who were not critically ill prior to transplantation.6,21

Another important consideration in the development and implementation of an ambulatory ECMO program of this nature is time spent on the waiting list. As an example, at Duke, the average waiting time for lung transplantation is 18 days, compared with a national average of 110 days.2 The waiting time varies considerably by donation service area and institution, and the decision to initiate ECMO in patients in these settings must be weighed carefully. On one hand, life support may increase the likelihood of survival to transplantation, but longer time on ECMO increases risk for complications, such as thromboembolism, bleeding, stroke, infection, and renal failure.31 Studies have demonstrated decreased survival with increasing duration of ECMO, and it may be suggested that centers with shorter wait times (< 1 month) have the best chance to successfully bridge patients to transplant with the minimum number of complications and improved outcomes.32,33 However, a publication reported a patient with nonambulatory ECMO receiving a successful lung transplant after 107 days of ECMO support.34 Whether ambulatory or not, the long-term outcomes for patients receiving transplant following a prolonged course of ECMO are not yet known. The overall impact on both patients and programs of potentially prolonged durations of ECMO while awaiting lung transplant remains unclear, and this approach may not be the most efficient use of resources in centers with lower numbers of transplants or longer wait times. The decision to transfer patients who may require advanced support to a center with increased volume and shorter waiting times may provide patients with an increased opportunity for early transplantation to avoid complications and improve posttransplant outcomes.

Improved outcomes in lung transplantation have been demonstrated in high-volume (> 20 cases/y) compared with lower-volume centers (< 20 cases/y), with a 50% decrease in 30-day censored 1-year mortality correlating to a 12% absolute risk reduction when comparing high- to low-volume centers.35 Given improved outcomes associated with higher transplant volumes, it is important to consider center volume when developing ambulatory ECMO programs.35,36 The Extracorporeal Life Support Organization recommends that ECMO centers should be tertiary care centers with a minimum of six cases per year,37 and there have been three pediatric studies demonstrating decreased mortality as ECMO center volume increases.3840 Jen and Shew38 found an increased survival above 14 cases per year, Freeman et al40 found a significant decrease in mortality above 22 cases, and Karamlou et al39 found a significant difference in hospital mortality when comparing centers performing < 15 cases compared with those performing > 15 cases. A study published by Barbaro et al41 evaluated ECMO volume in an all-age cohort and similarly demonstrated significantly improved mortality as center volume increased, with the greatest difference seen in centers performing > 30 cases each year. Center volume has been studied in depth for use in pediatric and neonatal patients with demonstration of significantly lower odds of death at medium- to high-volume centers compared with low-volume centers.39,42,43 These data provide support for the consideration for regionalization of ECMO care to improve patient outcomes while taking utmost care to not limit access to care in low-volume regions, suggesting that centers with high-volume lung transplantation and a well-established ECMO program may have the most success in the implementation of ambulatory ECMO for critically ill patients as they are bridged to lung transplantation.41

The growing body of literature demonstrating improved outcomes in centers with higher ECMO and transplant volumes highlights the importance of pooling resources to improve care. Patients requiring advanced support with ECMO likely benefit from utilization of centers with resources and expertise to manage high-risk cases. In addition, this strategy has also been demonstrated to decrease costs for the care of these critically ill patients.41,44 As potential regionalization is considered in this context, the impact on lung allocation and the performance of organ procurement organizations (OPOs) should also be considered. The impact of regionalization of ECMO care in the pretransplant population has not been studied, but we postulate this strategy may lead to alterations in the case mix index, LAS scores, and waiting times for an individual OPO. Although these most critically ill patients currently make up a small minority of transplants, it is possible that regionalization and increasing implementation of this approach may substantially change distribution of organs within an OPO. Regionalization of ECMO programs will likely increase the need for greater regional sharing of organs to ensure the sickest patients are offered transplant to minimize deaths on the waiting list as well as ensure that waitlist individuals are not disproportionally disadvantaged based on the current OPO boundaries.

Although there are a number of yet unanswered questions, the composite of the currently available data suggests that the formation of complex care models dedicated to successful bridging to transplant with ECMO may be most cost effective and beneficial at high-volume transplant centers with short wait times. It is our hope that regionalization of ECMO care will facilitate improved care for patients on the waiting list, with tiered complexity of care available at traditional transplant centers and transfer of care for critically ill patients who may benefit from ECMO to dedicated centers with rigorous pretransplant rehabilitation and ambulatory ECMO programs. The further specialization of care will allow focus on the strengths of each individual center while ensuring that individual centers are not overextended in an effort to provide all-encompassing transplant care.

The design and implementation of ambulatory ECMO protocols in centers remains a multidisciplinary, time-intensive effort, with the requirement of a dedicated and highly trained staff devoted to continual improvement and innovation within the program. It is anticipated that the development of regional centers with ambulatory ECMO expertise will provide an infrastructure to provide both high-quality and cost-effective care with a focus on improving outcomes for the most critically ill patients awaiting lung transplantation.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts: Dr Cheifetz has received medical advisory fees from Hill-Rom and Philips and grants to his institution from Philips, CareFusion Corp, Teleflex Inc, Hill-Rom, Covidien, and Ikaria, Inc. All disclosed support is outside the scope of this article. Drs Lehr, Zaas, and Turner have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

ECMO

extracorporeal membrane oxygenation

LAS

Lung Allocation Score

OPO

organ procurement organization

Lund LH, Edwards LB, Kucheryavaya AY, et al; International Society for Heart and Lung Transplantation. The registry of the International Society for Heart and Lung Transplantation: thirtieth official adult heart transplant report—2013; focus theme: age. J Heart Lung Transplant. 2013;32(10):951-964. [CrossRef] [PubMed]
 
Valapour M, Paulson K, Smith JM, et al. OPTN/SRTR 2011 annual data report: lung. Am J Transplant. 2013;13(suppl 1):149-177. [CrossRef] [PubMed]
 
Griffiths RD, Hall JB. Intensive care unit-acquired weakness. Crit Care Med. 2010;38(3):779-787. [CrossRef] [PubMed]
 
Reinsma GD, ten Hacken NH, Grevink RG, van der Bij W, Koëter GH, van Weert E. Limiting factors of exercise performance 1 year after lung transplantation. J Heart Lung Transplant. 2006;25(11):1310-1316. [CrossRef] [PubMed]
 
Nosotti M, Rosso L, Tosi D, et al. Extracorporeal membrane oxygenation with spontaneous breathing as a bridge to lung transplantation. Interact Cardiovasc Thorac Surg. 2013;16(1):55-59. [CrossRef] [PubMed]
 
Turner DA, Cheifetz IM, Rehder KJ, et al. Active rehabilitation and physical therapy during extracorporeal membrane oxygenation while awaiting lung transplantation: a practical approach. Crit Care Med. 2011;39(12):2593-2598. [PubMed]
 
Fuehner T, Kuehn C, Hadem J, et al. Extracorporeal membrane oxygenation in awake patients as bridge to lung transplantation. Am J Respir Crit Care Med. 2012;185(7):763-768. [CrossRef] [PubMed]
 
Jurmann MJ, Schaefers HJ, Demertzis S, Haverich A, Wahlers T, Borst HG. Emergency lung transplantation after extracorporeal membrane oxygenation. ASAIO J. 1993;39(3):M448-M452. [CrossRef] [PubMed]
 
Jurmann MJ, Haverich A, Demertzis S, Schaefers HJ, Wagner TO, Borst HG. Extracorporeal membrane oxygenation as a bridge to lung transplantation. Eur J Cardiothorac Surg. 1991;5(2):94-97. [CrossRef] [PubMed]
 
Fischer S, Simon AR, Welte T, et al. Bridge to lung transplantation with the novel pumpless interventional lung assist device NovaLung. J Thorac Cardiovasc Surg. 2006;131(3):719-723. [CrossRef] [PubMed]
 
Nosotti M, Rosso L, Palleschi A, et al. Bridge to lung transplantation by venovenous extracorporeal membrane oxygenation: a lesson learned on the first four cases. Transplant Proc. 2010;42(4):1259-1261. [CrossRef] [PubMed]
 
US Organ Procurement and Transplantation Network (OPTN), Scientific Registry of Transplant Recipients (SRTR). United States Organ Transplantation. OPTN/SRTR Annual Data Report 2010. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau. Division of Transplantation; 2011.
 
Pereszlenyi A, Lang G, Steltzer H, et al. Bilateral lung transplantation with intra- and postoperatively prolonged ECMO support in patients with pulmonary hypertension. Eur J Cardiothorac Surg. 2002;21(5):858-863. [CrossRef] [PubMed]
 
Aigner C, Wisser W, Taghavi S, et al. Institutional experience with extracorporeal membrane oxygenation in lung transplantation. Eur J Cardiothorac Surg. 2007;31(3):468-473. [CrossRef] [PubMed]
 
Jackson A, Cropper J, Pye R, Junius F, Malouf M, Glanville A. Use of extracorporeal membrane oxygenation as a bridge to primary lung transplant: 3 consecutive, successful cases and a review of the literature. J Heart Lung Transplant. 2008;27(3):348-352. [CrossRef] [PubMed]
 
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Javidfar J, Brodie D, Iribarne A, et al. Extracorporeal membrane oxygenation as a bridge to lung transplantation and recovery. J Thorac Cardiovasc Surg. 2012;144(3):716-721. [CrossRef] [PubMed]
 
Rehder KJ, Turner DA, Hartwig MG, et al. Active rehabilitation during extracorporeal membrane oxygenation as a bridge to lung transplantation. Respir Care. 2013;58(8):1291-1298. [CrossRef] [PubMed]
 
Garcia JP, Kon ZN, Evans C, et al. Ambulatory veno-venous extracorporeal membrane oxygenation: innovation and pitfalls. J Thorac Cardiovasc Surg. 2011;142(4):755-761. [CrossRef] [PubMed]
 
Hayes D Jr, Kukreja J, Tobias JD, Ballard HO, Hoopes CW. Ambulatory venovenous extracorporeal respiratory support as a bridge for cystic fibrosis patients to emergent lung transplantation. J Cyst Fibros. 2012;11(1):40-45. [CrossRef] [PubMed]
 
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Morris PE, Goad A, Thompson C, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med. 2008;36(8):2238-2243. [CrossRef] [PubMed]
 
Russo MJ, Davies RR, Hong KN, et al. Who is the high-risk recipient? Predicting mortality after lung transplantation using pretransplant risk factors. J Thorac Cardiovasc Surg. 2009;138(5):1234-1238. [CrossRef] [PubMed]
 
Lafç G, Budak AB, Yener AÜ, Cicek OF. Use of extracorporeal membrane oxygenation in adults. Heart Lung Circ. 2014;23(1):10-23. [CrossRef] [PubMed]
 
Brogan TV, Zabrocki L, Thiagarajan RR, Rycus PT, Bratton SL. Prolonged extracorporeal membrane oxygenation for children with respiratory failure. Pediatr Crit Care Med. 2012;13(4):e249-e254. [CrossRef] [PubMed]
 
Merrill ED, Schoeneberg L, Sandesara P, et al. Outcomes after prolonged extracorporeal membrane oxygenation support in children with cardiac disease—Extracorporeal Life Support Organization registry study. J Thorac Cardiovasc Surg. 2014;148(2):582-588. [CrossRef] [PubMed]
 
Iacono A, Groves S, Garcia J, Griffith B. Lung transplantation following 107 days of extracorporeal membrane oxygenation. Eur J Cardiothorac Surg. 2010;37(4):969-971. [CrossRef] [PubMed]
 
Weiss ES, Allen JG, Meguid RA, et al. The impact of center volume on survival in lung transplantation: an analysis of more than 10,000 cases. Ann Thorac Surg. 2009;88(4):1062-1070. [CrossRef] [PubMed]
 
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ELSO guidelines for ECMO centers. Extracorporeal Life Support Organization website. https://www.elso.org/Resources/Guidelines.aspx. Published 2010. Accessed October 1, 2014.
 
Jen HC, Shew SB. Hospital readmissions and survival after nonneonatal pediatric ECMO. Pediatrics. 2010;125(6):1217-1223. [CrossRef] [PubMed]
 
Karamlou T, Vafaeezadeh M, Parrish AM, et al. Increased extracorporeal membrane oxygenation center case volume is associated with improved extracorporeal membrane oxygenation survival among pediatric patients. J Thorac Cardiovasc Surg. 2013;145(2):470-475. [CrossRef] [PubMed]
 
Freeman CL, Bennett TD, Casper TC, et al. Pediatric and neonatal extracorporeal membrane oxygenation: does center volume impact mortality? Crit Care Med. 2014;42(3):512-519. [CrossRef] [PubMed]
 
Barbaro R, Odetola F, Kidwell K, et al. Association of mortality with hospital-level extracorporeal membrane oxygenation patient volume [abstract]. Crit Care Med. 2013;41(12):A7. [CrossRef]
 
Peek GJ, Mugford M, Tiruvoipati R, et al; CESAR trial collaboration. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374(9698):1351-1363. [CrossRef] [PubMed]
 
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References

Lund LH, Edwards LB, Kucheryavaya AY, et al; International Society for Heart and Lung Transplantation. The registry of the International Society for Heart and Lung Transplantation: thirtieth official adult heart transplant report—2013; focus theme: age. J Heart Lung Transplant. 2013;32(10):951-964. [CrossRef] [PubMed]
 
Valapour M, Paulson K, Smith JM, et al. OPTN/SRTR 2011 annual data report: lung. Am J Transplant. 2013;13(suppl 1):149-177. [CrossRef] [PubMed]
 
Griffiths RD, Hall JB. Intensive care unit-acquired weakness. Crit Care Med. 2010;38(3):779-787. [CrossRef] [PubMed]
 
Reinsma GD, ten Hacken NH, Grevink RG, van der Bij W, Koëter GH, van Weert E. Limiting factors of exercise performance 1 year after lung transplantation. J Heart Lung Transplant. 2006;25(11):1310-1316. [CrossRef] [PubMed]
 
Nosotti M, Rosso L, Tosi D, et al. Extracorporeal membrane oxygenation with spontaneous breathing as a bridge to lung transplantation. Interact Cardiovasc Thorac Surg. 2013;16(1):55-59. [CrossRef] [PubMed]
 
Turner DA, Cheifetz IM, Rehder KJ, et al. Active rehabilitation and physical therapy during extracorporeal membrane oxygenation while awaiting lung transplantation: a practical approach. Crit Care Med. 2011;39(12):2593-2598. [PubMed]
 
Fuehner T, Kuehn C, Hadem J, et al. Extracorporeal membrane oxygenation in awake patients as bridge to lung transplantation. Am J Respir Crit Care Med. 2012;185(7):763-768. [CrossRef] [PubMed]
 
Jurmann MJ, Schaefers HJ, Demertzis S, Haverich A, Wahlers T, Borst HG. Emergency lung transplantation after extracorporeal membrane oxygenation. ASAIO J. 1993;39(3):M448-M452. [CrossRef] [PubMed]
 
Jurmann MJ, Haverich A, Demertzis S, Schaefers HJ, Wagner TO, Borst HG. Extracorporeal membrane oxygenation as a bridge to lung transplantation. Eur J Cardiothorac Surg. 1991;5(2):94-97. [CrossRef] [PubMed]
 
Fischer S, Simon AR, Welte T, et al. Bridge to lung transplantation with the novel pumpless interventional lung assist device NovaLung. J Thorac Cardiovasc Surg. 2006;131(3):719-723. [CrossRef] [PubMed]
 
Nosotti M, Rosso L, Palleschi A, et al. Bridge to lung transplantation by venovenous extracorporeal membrane oxygenation: a lesson learned on the first four cases. Transplant Proc. 2010;42(4):1259-1261. [CrossRef] [PubMed]
 
US Organ Procurement and Transplantation Network (OPTN), Scientific Registry of Transplant Recipients (SRTR). United States Organ Transplantation. OPTN/SRTR Annual Data Report 2010. Rockville, MD: Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau. Division of Transplantation; 2011.
 
Pereszlenyi A, Lang G, Steltzer H, et al. Bilateral lung transplantation with intra- and postoperatively prolonged ECMO support in patients with pulmonary hypertension. Eur J Cardiothorac Surg. 2002;21(5):858-863. [CrossRef] [PubMed]
 
Aigner C, Wisser W, Taghavi S, et al. Institutional experience with extracorporeal membrane oxygenation in lung transplantation. Eur J Cardiothorac Surg. 2007;31(3):468-473. [CrossRef] [PubMed]
 
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