Management of Respiratory Failure: The Surgical Perspective. When Traditional Respiratory Support Techniques fail. ARDS: Evidence Based Practice

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1 Critical Care Medicine and Trauma Management of Respiratory Failure: The Surgical Perspective Jasleen Kukreja, M.D. Division of Cardiothoracic Surgery University of California San Francisco When Traditional Respiratory Support Techniques fail Extracorporeal membrane oxygenation can be utilized for: Short term management (in the operating room or initial stabilization of ventilatory failure) Long-term management (as a bridge to recovery or transplantation) ARDS: Evidence Based Practice 2 RCTs from 1979 and 1994 failed to show survival advantage for ECMO in ARDS Several case series since supported the use of ECMO in ARDS CESAR RCT in UK has led to resurgence of ECMO in ARDS 1

2 Volume 374, Issue 9698, 17 October October 2009, Pages Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial Giles J Peek MD, Prof Miranda Mugford DPhilc, Ravindranath Tiruvoipati FRCSE, Prof Andrew Wilson MD, Elizabeth Allen PhD, Mariamma M Thalanany MSc, Clare L Hibbert PhD, Ann Truesdale BSc, Felicity Clemens MSc, Nicola Cooper PhD, Richard K Firmin MBBS, Prof Diana Elbourne PhD and for the CESAR trial collaboration CESAR: Management After Randomization 2

3 CESAR: Death and Disability CESAR: Kaplan Meier Survival Estimates CESAR: Length of Stay 3

4 UCSF Algorithm for ECMO Deployment Airway (Short term) Traumatic tracheobronchial injuries Central Endolumenal obstructive physiology Parenchymal (Long term) Bridge to recovery (ARDS, H1N1, PNA) Bridge to healing from bronchopleural fistulas Bridge to transplant Choice of ECLS (Extracorporeal Life Support) Venoarterial (VA) versus Venovenous (VV) VA ECMO Higher PaO 2 is achieved. Lower perfusion rates are needed. Bypasses pulmonary circulation Decreases pulmonary artery pressures Provides cardiac and pulmonary support Requires arterial cannulation VV ECMO Lower PaO 2 is achieved. Higher perfusion rates are needed. Maintains pulmonary blood flow Elevates mixed venous PO 2 Only provides pulmonary support Requires only venous cannulation Traditional ECMO VA ECMO VV ECMO 4

5 Avalon Bi-caval Dual-Lumen Cannula Single percutaneous venous cannulation via internal jugular Can be performed at bedside May be extubated Early mobilization and ambulation Avalon Bicaval Dual-Lumen Cannula Bicaval dual-lumen cannula with 3 ports Proximal inflow port in SVC Distal inflow port in IVC Medial outflow infusion port in RA Avalon Bi-Caval Cannula Imaging Flouroscopic Confirmation Echocardiographic Guided 5

6 UCSF ECMO Experience Case 1-Traumatic Tracheal Tear ECMO Brigde to Recovery 42 y/o F on chronic steroids for congenital adrenal hyperplasia with h/o methamphetamine abuse was painting a car when she became acutely SOB : -Intubated by EMS in the field -Developed sq emphysema -CT of the chest Case 1 Patient was transferred by LifeFlight to UCSF for further treatment On arrival: B/L tension PTX requiring B/L chest tube placement Severe respiratory acidosis Admission ABG: ph 6.9 / pco2 146 / po2 322 / HCO3 27 Could not be ventilated 6

7 Emergently went to OR upon arrival for Avalon VV ECMO via Right IJ under flouro/echo guidance Case 1 Postop ABG: ph 7.39 / pco2 26 / po2 64 Stabalized overnight Case 1 Day #1 on ECMO After stabilization of acute hypercarbia, underwent R thoracotomy & primary repair of posterior tracheal tear on ECMO Weaned off ventilator within 24 hrs after repair Discharged home 2 wks later Case 2 - BPF/Bridge to Transplant 24 yo F with CF, DM, HTN who had been awaiting lung transplant developed: Developed left sided tension pneumothorax in the setting of PNA L pigtail placed, but with persistent large bronchopleural fistula Patient transferred to UCSF for further management 7

8 Case 2 Progressive ventilatory and hypoxic failure ABG: ph 7.27 / pco2 105 / po2 42 / HCO3 46 Intubated and trached Case 2 6 days post intubation underwent Avalon VV ECMO via RIJ under flouro and TEE guidance ABG: ph 7.50 / pco2 56 / po2 63 / HCO3 43 Conclusion Increased awareness and early referral ECMO Center of Excellence Careful patient selection Multi-disciplinary approach Large resources and Infra-structure NOVA lung 8

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