Hospital Authority Convention 2015
ECMO/
ECCO2R + Ultra-protective Lung Ventilation
Dr. Yan Wing Wa
Department of Intensive Care
Pamela Youde Nethersole Eastern Hospital
19 May 2015
1
2
Scope
Two forms of ECMO
ECMO - high flow
Extracorporeal CO2 Removal (ECCO2R) - low flow
Roles in management of ARDS?
Types ECCO2R available
Acute respiratory distress syndrome (ARDS)
Injured lung need rest till recovery but
Injured lung need to maintain adequate O2 saturation
More severe injury need more vent. pressures, PEEP,
FiO2
More ventilator induced lung injury
Oxygen toxicity
Vicious cycle
Protective Lung Ventilation (PLV)
Tidal volume
6ml/kg vs. 12ml/kg
Anesthesiology 2009;111:826-35
Ultra-Protective Lung Ventilation
2 Forms of ECMO
Extracorporeal membrane oxygenation (ECMO)
High flow (4 – 6 L/min)
Both oxygenation & CO2 removal
Extracorporeal CO2 removal (ECCO2R)
Low flow (0.5 to 1 L/min)
Only CO2 removal
7
Extracorporeal flow needed F
low
ml/m
in
10
100
1000
10000
CRRT IHD
ECMO
ECCO2R
Physiology Of O2 delivery
O2 consumption ~ 240 ml/min
Amount of O2 added to the
blood via ECMO ~ 40-60 ml/L
1.34 * Hb * (SoutO2 – SinO2)
4 – 6 L/min blood flow is
needed
Physiology of CO2 removal
CO2 generation ~ 200 ml/min
Amount of CO2 stored in blood
~ 500 ml/L
Achieved adequate CO2
removal with < 1L/min
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ECCO2R
Gattinoni L,et al. Low-frequency positive pressure ventilation with extracorporeal carbon dioxide removal : an experimental study. Anesth Analg 1978, 57:470-477
Randomized Control Trials
Fitzgerald M et al. ECCO2R for patients with acute respiratory failure secondary to the ARDS: a
systematic review. Critical Care 2014,18:222
Outlook of ECCO2R
No definitive conclusions can be drawn at this stage for ARDS Sample sizes too small
Negative RCT
No mortality benefit
Do have improvements in PaCO2, lower tidal volume, plateau pressure, +/-ventilator-free day
Possible other roles COPD failing NIV
Status asthmaticus
Bridge to lung transplant
Complications Cannulation risk similar to renal replacement therapy
Circuit thrombosis, bleeding
Trial Indication Type Number of subjects Estimated End
SUPERNOVA
ARDS Pilot-to-
Pivotal
Ultraprotective
ventilation in Moderate
to Severe ARDS
Prospective, ESICM-led Single-arm Pilot 100
Pivotal 2,050
Q3 2019
REST ARDS
Pilot-to-Pivotal
Ultraprotective
ventilation in Moderate
to Severe ARDS
Prospective, UK funded, consortium-led Single-arm Pilot 40
Pivotal 1,120
Q4 2019
Singapore ARDS
Pilot
Ultraprotective
ventilation and
recruitment in Moderate
to Severe ARDS
Prospective, Investigator-Initiated Pilot
RCT
50 (25/25) Q1 2016
HAVAnA Trial
(The
Netherlands)
Effects of induced
hyperthermia with
novatherm and iLA-
activve minilung in
Moderate ARDS
Prospective, Feasibility Study 30 Not yet recruiting
ALung ARDS
Feasibility
Ultraprotective
ventilation in Moderate
to Severe ARDS
Prospective, Investigator- Initiated
Feasibility Study
15 Q4 2014
PARSA Trial
(France)
Pulmonary and renal
support for adult
patients experiencing
both ARDS and acute
renal failure
Prospective, Single-arm Feasibility Study 10 Recruiting
Clinical Trials (ARDS)
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Types & Devices for ECCO2R
Arteriovenous CO2 Removal (AVCO2R)
Pumpless Extracorporeal Lung Assist (PECLA)
Venovenous CO2 Removal (VVCO2R)
Decap/Decap-Smart
Hemolung
iLA Activve
Typical VV-ECMO set up
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AVCO2R or PECLA
iLA Membrane Ventilator, Novalung, GmbH, Germany
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AVCO2R or PECLA
Novalung: interventional Lung Assist (iLA) membrane ventilator
Hemodynamic should be stable, with MAP >60mmHg
Flowmeter monitoring is needed
Risk of distal limb ischemia
Indications
UPLV for ARDS
Status asthmaticus
Bridge to lung transplantation
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Hemodec, Salerno, Italy
Allow CO2 removal + Renal Replacement Therapy
Successful trials in adults and children
*Terragni PP, Gattinoni L, Ranieri VM et al: Tidal volume lower than 6 ml/kg enhances lung protection: role of
extracorporeal carbon dioxide removal. Anesthesiology 2009, 111:826-835
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Alung Technologies, Pittsburgh, USA
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Venovenous CO2 Removal
Move gradually to VV-ECMO
Typical VV-ECMO circuit
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Jugular vein
Femoral vein
Membrane
lung
Circuit pump
Oxygen
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Thank you.