Management of native lung in ECMO

Report
Management of native lung on ECMO
Roberto Fumagalli
Ospedale Niguarda Ca’ Granda
Università degli Studi Milano Bicocca
Milano
Disclosure: none
The Oxygenator in Venovenous ECMO.
Brodie D, Bacchetta M. N Engl J Med 2011;365:1905-1914
OXYGENATION
FiO2 =1.0 250 mL min-1
7000 mL min-1
PBF
Hb 15 g
Satv82%
PvO247 mmHg
CO2 cont 52 mL
PvCO243 mmHg
Sata98%
PaO2110 mmHg
VO2
250
mL min-1
CO2 REMOVAL
VA 2-4 L min-1
1100 mL min-1
PBF
CO2 cont 34 mL
PaCO215 mmHg
VCO2
200
mL min-1
Gattinoni et al., European Advances in Intensive Care, 1983; 21: 97-117
Arterial Oxygen Saturation (%)
ECMO
mathematical model
100
Steady state
95
90
Shunt 40%
85
Shunt 50%
80
Shunt 60%
75
10
20
30
40
50
ECMO Blood Flow (%CO)
60
70
gas flow 10 l/min
4
1 10
9000
PaCO2
8000
VE
50
49
48
7000
-1
47
6000
46
45
44
3000
43
2000
42
1000
41
0
0
6
12
18
24
30
36
42
Time (h)
48
54
60
66
72
(mmHg)
4000
PaCO (mmHg)
5000
2
VE (mL*min )
EC onset
BEWARE
pH
PCO2 !!
– RR (always)
– TV (almost always)
– I/E ( watch out)
• Guided by:
– EndTidalCO2
– ABG
• in 10’
Mean airways pressure
FR = 30
FR = 15
Paw = [(30*1) + (15*2)] / 3 = 20
Paw = [(30*1) + (15*1)] / 2 = 22.5
30
30
1”
15
1”
1”
15
2”
BE HAPPY
• Pplat < 30
• TV < 6 ml/Kg or even lower
Rate: 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 second
access
cannula was needed to augment
ECMO 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
•
•
•
•
RMs
PEEP Titration
SIGH
PNX ?
Opening and closing pressures
Paw > 35
50
to fully recruit
40
%
cmH2O
Opening
pressure
30
Closing
pressure
20
10
0
0
5
10 15
20 25 30 35 40 45 50
Paw [cmH2O]
Crotti et al. Am J Respir Crit Care Med 2001
Modern PEEP Titration
12
10
10
7
15
Effects of periodic lung recruitment maneuvers on gas exchange and
respiratory mechanics in mechanically ventilated ARDS patients.
G. Foti, M.Cereda, M.E. Sparacino, L. De Marchi,F. Villa, A. Pesenti
Intensive Care Med (2000) 26: 501-507
Pressione di reclutamento
Sigh (1 ogni 3 min)
SIGH
Oxygenation
 Qva/Qt
Always keeping in mind that
Packer et al Crit Care Med 1993;31:131-143
SPECIFIC HYPERVENTILATION
FRC
VE
(L/min)
RATIO
NORMAL
2500
7
2.8
ARDS
500
12
24
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 al
Am Rev Resp Dis 1987, 135: 312-315
Group A
Group B
Group C
Normal
5
-
-
Light
damage
Moderate
1
-
-
2
1
1
Severe
-
1
-
Very severe
-
5
8
Kolobow T, Moretti MP , Fumagalli R et al
Am Rev Resp Dis 1987, 135: 312-315
Spontaneous breathing in ARDS
spontaneous breathing
controlled ventilation, NMBA
The lung rest concept
Control of breathing using an
extracorporeal membrane lung
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

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