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Roberto FumagalliOspedale Niguarda Ca’ GrandaUniversità degli Studi Milano BicoccaMilanoDisclosure: none
Management of native lung on ECMO
The Oxygenator in Venovenous ECMO.
Brodie D, Bacchetta M. N Engl J Med 2011;365:1905-1914
OXYGENATIONFiO2 =1.0 250 mL min-1
VO2250
mL min-1
Sata98%
PaO2110 mmHgHb 15 gSatv82%
7000 mL min-1
PBF
CO2 REMOVALVA 2-4 L min-1
VCO2200
mL min-1
CO2 cont 34 mL
PaCO215 mmHg
PvO247 mmHgCO2 cont 52 mLPvCO243 mmHg
1100 mL min-1
PBF
Gattinoni et al., European Advances in Intensive Care, 1983; 21: 97-117
Arte
rial O
xyge
n Sa
tura
tion
(%)
Steady state100
ECMOmathematical model
ECMO Blood Flow (%CO)
10 20 30 40 50 60 70
95
90Shunt 40%
85Shunt 50%
80Shunt 60%
75
VE
(mL
*min
)
PaCO
(mm
Hg)
(mm
Hg)
-12
1 10 4
PaCO2
VE
gas flow 10 l/min EC onset
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
50
49
48
47
46
45
44
43
42
41
0 6 12 18 24 30 36 42 48 54 60 66 72
Time (h)
BEWARE pH PCO2 !!
– RR (always)– TV (almost always)– I/E ( watch out)
• Guided by:– EndTidalCO2– ABG
• in 10’
FR = 30
Paw = [(30*1) + (15*1)] / 2 = 22.5
30
Mean airways pressure
FR = 15
Paw = [(30*1) + (15*2)] / 3 = 20
30
1” 1”
15
1” 2”
15
BE HAPPY
• Pplat < 30• TV < 6 ml/Kg or even lowerRate: under debate: 3-10 bpm
NO GOOD BETTER
Ventillatory strategies in ECMO
Recruiter Non Recruiter
lung rest settings were :- peak inspiratory pressure 20–25,- positive endexpiratory pressure 10–15,- rate 10,- FiO2 0・ 3.
• Minute ventilation was then reduced by adjusting frequency and inspiratory pressure. PEEP was increased to ventilate the patient with the least possible mechanical stress while maintaining a sufficient level of oxygenation (oxygen saturation by pulse oximetry [SpO2] ≥90%).
Ventilator settings were reduced to rest settings as soon as possible after transport to Stockholm and
when stable on by-pass. Peak inspiratory pressures were adjusted to 20-25 cm H20, PEEP5-10 cm H20
and FiO2 0.4.
Non Recruiter strategy
In 33 patients (49%), a secondaccess
cannula was needed to augmentECMO support.
Non Recruiter strategy• Low PEEP (5-10)• LPS
– PSV• High Blood Flow
– II° drainage cannula• NO PNX• Pulmonary Hypertension
– V-A bypass?
B.F.
Recruiter strategy••••
RMsPEEP TitrationSIGHPNX ?
%
Opening and closing pressures50
OpeningpressureClosingpressure
Paw > 35cmH2Oto fully recruit
0 5
40
30
20
10
010 15 20 25 30 35 40 45 50
Paw [cmH2O]Crotti et al. Am J Respir Crit Care Med 2001
Modern PEEP Titration
10 1215
710
Sigh (1 ogni 3 min)
Effects of periodic lung recruitment maneuvers on gas exchange andrespiratory mechanics in mechanically ventilated ARDS patients.
G. Foti, M.Cereda, M.E. Sparacino, L. De Marchi,F. Villa, A. PesentiIntensive Care Med (2000) 26: 501-507
Pressione di reclutamento
↑Oxygenation↓ Qva/Qt
SIGH
Always keeping in mind that
Packer et al Crit Care Med 1993;31:131-143
FRC VE (L/min) RATIO
NORMAL
ARDS
2500 7 2.8
500 12 24
SPECIFIC HYPERVENTILATION
Hager DN AmJ Respir Crit Care Med :2005: 172: 1241
• Normal sheeps randomly assigned to 3 groups:• A: control MV 48 hrs• B: PIP 50 cm H2O RR 1-3 bpm• C: PIP 50 cm H2O RR 12 bpm CO2 3.8
Kolobow T, Moretti MP , Fumagalli R et alAm Rev Resp Dis 1987, 135: 312-315
Group A Group B Group C
Normal 5 - -
Light damage
1 - -
Moderate 2 1 1
Severe - 1 -
Very severe - 5 8
Kolobow T, Moretti MP , Fumagalli R et alAm Rev Resp Dis 1987, 135: 312-315
Spontaneous breathing in ARDS
spontaneous breathing controlled ventilation, NMBA
Control of breathing using anextracorporeal membrane lung
The lung rest concept
Kolobow T, Gattinoni et al., Anesthesiology, 1977; 46: 138-141
• The most appropriate ventilator settings for patients with severe ARDS who are undergoing ECMO are unknown.
Whenever possible, we aim for limitation of pressure and set respiratory rates that are at least as restrictive as those described above, along with tidal volumes that are typically main- tained below 4 ml per kilogram of predicted body weight, to minimize the potential for ventilator- associated lung injury. Whatever the approach, applying adequate PEEP is important to maintain airway patency at the low lung volumes attained with these settings.
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