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Mechanical Ventilation during ECMOHow, Why, Future Studies
Eddy Fan MD, FRCPCCritical Care Medicine
Mount Sinai Hospital and University Health Network
Assistant Professor of Medicine
Interdepartmental Division of Critical Care Medicine
Department of Medicine, University of Toronto
Extracorporeal Life SupportCanada Critical Care Forum – October 30, 2012
Disclosures/COI
• No relevant financial relationships with any commercial interests
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Mortality Before
Discharge Home
(Percent)
6 ml/kg 12 ml/kg
P=0.005High Stretch(Control)
- VT: 11.8
- PPLAT: 32-34
- RR: 18
- VMIN: 13
- PEEP: 8
Low Stretch (Intervention)
- VT: 6.2 mL/kg
- PPLAT: 25 cmH2O
- RR: 29
- VMIN: 13 L/min
- PEEP: 9 cmH2O
The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342:1301-1308.
Terragni PP et al. Am J Respir Crit Care Med 2007;175:160-166.
TREAT THE “BABY LUNG” GENTLY
Needham DM et al., BMJ 2012;344:e2124.
Brodie D and Bacchetta M, N Engl J Med 2011;365:1905-1914.
• VV ECMO provides gas exchange support only
– Blood drained from venous system and returned to venous system (e.g., jugular and femoral veins)
ECMO and Lung Rest – Limit VALI
• Subgroup of severe ARDS patients in which maintaining modest physiologic goals with lung protective MV is not possible
– Extracorporeal gas exchange may facilitate lung rest and prevent the need for injurious MV
– Complete apnea to spontaneous breathing
THE BEST WAY TO TREAT THE “BABY LUNG” GENTLY?
Terragni PP et al., Anesthesiology 2009;111:826-835.
• Reductions in ECCO2R group• VT from 6.3 to 4.2 mL/kg PBW• Pplat from 29.1 to 25.0 cmH2O
• ECCO2R normalized PaCO2 (50.4 mmHg) and pH (7.32) despite lower VT
• After 72 hrs of ventilation and ECCO2R• Significant improvement in
morphological markers of lung protection and pulmonary cytokines
• No patient-related complications observed
Muellenback RM et al., Med Sci Monit 2009;BR213-220.
How much should we “rest” the lung in patients with severe
ARDS on ECMO?
Lung Rest Ventilation During ECMO
• Appropriate MV settings for severe ARDS patients on ECMO are unknown– Optimal tidal volume?
– Optimal PEEP?
• Various strategies to achieve lung rest have been described– Effects on inflammatory markers/outcomes have
not been compared
– Role of spontaneous ventilation/extubation?
Brodie D and Bacchetta M. N Engl J Med 2011;365:1905-1914.
Peek GJ et al., Lancet 2009;374:1351-1363.
6-month survival without disabilityRR 0.69 (95% CI 0.05-0.97)
EOLIAECMO to rescue Lung Injury in severe ARDS
PI: Prof. Alain Combes
To Open, or Not to Open?
• Recruited lung
– Less likely to develop pneumonia
– Better surfactant function
– Less VALI?
– Improved outcomes?
• And if so, how to recruit, and at what cost?
– Potential for recruitment? “Inert” atelectasis?
– Overdistention/inhomogeneity – more VALI?
Kacmarek RM. Crit Care 2006;10:158.Grasso S et al., Am J Respir Crit Care Med 2009;180:415-423.Bellani G et al., Am J Respir Crit Care Med 2011;183:1193-1199.
Kolobow T et al., J Thorac Cardiovasc Surg 1978;75:261-266.
“We had arbitrarily chosen 5 cmH2O pressure to keep the lungs inflated above FRC. We do not know at this time whether this represents the optimal requirement or whether pressure is desirable or even necessary for optimal performance….
This study was not undertaken to extend the safe period of apnea during electroconvulsive therapy, bronchoscopy….Rather we feel the concept of long-term (as opposed to short-term) apnea with extracorporeal carbon dioxide removal can affect present practice of mechanical pulmonary ventilation in especially difficult cases.”
Gattinoni L et al., Anesth Analg 1978;57:470-477.Gattinoni L et al., JAMA 1986;256:881-886.
Fuehner T et al., Am J Respir Crit Care Med 2012;185:763-768.
The SOLVE ARDS Study
Strategies for Optimal Lung Ventilation in ECMO for ARDS
A Goffi, K Mandelzweig, M Meineri, L Del Sorbo, E Goligher, S Abrahamson,
N Ferguson, A Slutsky, E Fan
