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.

THANKS