ECMO- ExtraCorporeal Membrane Oxygenation

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05/04/203 ECMO- ExtraCorporeal Membrane Oxygenation ECMO AS BRIDGE TO LUNG TRANSPLANTATION: PHYSIOTHERAPEUTIC

extracorporeallife support where an external artificial circuit carries venous blood from the patient to an

The blood is than returned to the patient viaaveinoranartery LUNG TRANSPLANTATION 20 ECMO Bridge Lung Transplantation

$refractory hypoxaemia and/o hypercapnia despiteoptimalmedical therapyandnon invasive ventilation.$

1 05/04/203 ECMO- ExtraCorporeal Membrane Oxygenation ECMO AS BRIDGE TO LUNG TRANSPLANTATION: PHYSIOTHERAPEUTIC INTERVENTION Sara Mariani Physiotherapist Fondazione IRCCS Ospedale Maggiore Policlinico Milano a form of extracorporeallife support where an external artificial circuit carries venous blood from the patient to an oxigenetor where blood is enriched with oxigen and has carbon dioxid removed. The blood is than returned to the patient viaaveinoranartery LUNG TRANSPLANTATION 20 ECMO Bridge Lung Transplantation Pub Med search before during after ECMO Bridge ECMO Support ECMO PGD RECIPIENT Bittern 202 n. of references ECMO as bridge to lung transplantation is performed in case of respiratory failure with refractory hypoxaemia and/o hypercapnia despiteoptimalmedical therapyandnon invasive ventilation. Falcoz PE, Thorax Year Lang, Transplantation (202);93:729 Bittner, Ann Thor Surg (202);94:942

05/04/203 975- st case of ECMO used as a bridge to lung transplant was performed 99 Hannover group published the first report of long-term survival after using ECMO as bridge to re-do lung

transplant is still notable, with one year survival is 80%.

EMOLISI related COMPLICATIONS CANNULA related BLEEDING TROMBOSIS DISPLACEMENT OBSTRUCTION V V ECMO is preferred while HYPOXEMIA with PCO2 elevation occurs with stable hemodinamics ( risk from

2 05/04/ st case of ECMO used as a bridge to lung transplant was performed 99 Hannover group published the first report of long-term survival after using ECMO as bridge to re-do lung transplant Ecmo had been proven to be a strong risk factor for mortality after transplantation in multivariable analysis Mason 200: 50% one year survival Overall mortality following lung transplant is still notable, with one year survival is 80%. increased mortality in the early phase after LTX increased postoperative length of stay the ADVERSE EFFECTS of patients who underwent transplantation while awaiting on the support device. EMOLISI related COMPLICATIONS CANNULA related BLEEDING TROMBOSIS DISPLACEMENT OBSTRUCTION V V ECMO is preferred while HYPOXEMIA with PCO2 elevation occurs with stable hemodinamics ( risk from systemic emboliza on inherent with arterial cannula) - HEMORRAGE - CANNULATION SITE COMPLICATIONS - RENAL FAILUR - SEPSIS - NEUROLOGIC COMPLICATIONS - LEG HISCHEMIA.. Fischer 2007 Kolla 997 Lang 202 V A ECMO is recommended when Hypoxemic respiratory failure and hemodinamic compromise ( risk of rates of neurological complica ons) 2

3 05/04/203 Now think about an ECMO patient Now think about an ECMO patient? Now think about an ECMO patient? 3

05/04/203 AWAKE vs INTUBATED Avoid drawbacks of endotracheal intubation, long term mechanical ventilation, sedation and bed rest Prevent septic complications, diaphragmatic weakness, muscles

4 05/04/203 AWAKE vs INTUBATED Avoid drawbacks of endotracheal intubation, long term mechanical ventilation, sedation and bed rest Prevent septic complications, diaphragmatic weakness, muscles deconditioning and critical illness myopathy Chastre J AJRCCM 2002 Hermans G Crit Care 2008 Vassilakopoulos T AJRCCM 2004 Mason DP Cardiovasc Surg 2009 IN CYSTIC FIBROSIS Poor prognoses and outcomes of patients with cystic fibrosis treated by MV. Efraty O, Heart Lung 200 to avoid the potential drawbacks of orotracheal intubation and long-term MV, particularly septic complications, in a cystic fibrosis patient, VV ECMO is feasible in awake and non-intubated patients. Bartosik ICVTS 20 Olsson Am J Transplant 200 AWAKE ECMO Olsson Am J Transplant 200 Nosotti Transplant Proc 200 Broomé Ann Thorac Surg 2008 Bartosik ICVTS 20 pts desease days ECMO 5 Pulmonary Hypertension 8 35 V A Awake, spontaneously breathing, eat, drink, watching TV. 4, PF 0 2 V V pt awake alveolitis secondary to polymyositis 2 bronchiolitis obliterans, BPCO 52 V V Femfemoral kept awake most of the time tracheostomy 4 40 Novalung Awake and spontaneously breathing patient 4

5 05/04/203 Physical therapy initiated in the intensive care unit a mobility protocol initiated earlier physical therapy that was feasible, safe, did not increase costs, and was associated with decreased intensive care unit and hospital length of stay in survivors who received physical therapy during intensive care unit Protocol, n = 65; Usual Care, n = 65. Morris PE, Crit Care Med physical and occupational therapy in the earliest days of critical illness-was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium and more ventilator-free days compared with standard care. Several studies have suggested that early ambulation is advantageous for patients in the ICU. This is particularly important for lung transplantation candidates, in whom there is a direct correlation between functional status and exercise capacity with outcomes. Thabut G, Am J Respir Crit Care Med patients Schweickert WD, Lancet 2009 Risk factors associated with critical illness myopathy Severe systemic inflammation Corticosteroids Neuromuscular blocking agents Diabetes Immobility Stevens R, Int Care Med 2007 Patients receive high doses of corticosteroids immediately after the lung transplantation. These relatively high doses of corticosteroids surely can induce steroid induced myopathy. Decramer M, Am J Respir Crit Care Med 996 role of ACTIVE MOBILITAZION in AWAKE ECMO PTS This worsening weakness is known to play a substantial role in the outcome of critically ill patients undergoing lung transplantation Maury G, Am J Transplant 2008 Reinsma GD, J Heart Lung Transplant 2006 Ambulation and preparation for lung transplant would normally be out of the question. Fortenberry Crit Care Med 20 (editorial) maximize muscle strength make the pt a «good candidate» 5

05/04/203 AMBULATORY ECMO- out of bed physiotherapy N DAYS O V-A PT PROGRAM RESPIRATION Turner Crit Care Med 20 3 age 6-24 7-4 Stand, walk, exercise program Mangi JTCS 200 age 34 3 V-A axillary vein

rehab (3 in room, tredmill) Passive and active exercises at the bedside and out of bed Active and passive PT, ambulate 2/4 tracheostomy NIV Hayes J 202 4 after EI 23 34 2 5 8.

Turner Crit Care Med 20 3 age 6-24 7-4 Stand, walk, exercise program Turner Crit Care Med 20 3 age 6-24 7-4 Stand, walk, exercise program Mangi JTCS 200 age 34 3 V-A axillary vein Ambulate Bipap to

6 05/04/203 AMBULATORY ECMO- out of bed physiotherapy N DAYS O V-A PT PROGRAM RESPIRATION Turner Crit Care Med 20 3 age Stand, walk, exercise program Mangi JTCS 200 age 34 3 V-A axillary vein Ambulate Bipap to prevent atelectasis Garcia JTCS 20 Lowman JD Cardiopulmonary Physical Therapy Journal 202 Reeb, ICVTS (bridge,ards) 6 weaned from MV age 6 age ± pts active rehab (3 in room, tredmill) Passive and active exercises at the bedside and out of bed Active and passive PT, ambulate 2/4 tracheostomy NIV Hayes J after EI ambulate and perform physical therapy AMBULATORY ECMO- out of bed physiotherapy AMBULATORY ECMO- out of bed physiotherapy N DAYS O V-A PT PROGRAM RESPIRATION N DAYS O V-A PT PROGRAM RESPIRATION Turner Crit Care Med 20 3 age Stand, walk, exercise program Turner Crit Care Med 20 3 age Stand, walk, exercise program Mangi JTCS 200 age 34 3 V-A axillary vein Ambulate Bipap to prevent atelectasis Mangi JTCS 200 age 34 3 V-A axillary vein Ambulate Bipap to prevent atelectasis Garcia JTCS 20 Lowman JD Cardiopulmonary Physical Therapy Journal 202 Reeb, ICVTS (bridge,ards) 6 weaned from MV age 6 age ± pts active rehab (3 in room, tredmill) Passive and active exercises at the bedside and out of bed Active and passive PT, ambulate 2/4 tracheostomy NIV Garcia JTCS 20 Lowman JD Cardiopulmonary Physical Therapy Journal 202 Reeb, ICVTS (bridge,ards) 6 weaned from MV age 6 age ± pts active rehab (3 in room, tredmill) Passive and active exercises at the bedside and out of bed Active and passive PT, ambulate 2/4 tracheostomy NIV Hayes J after EI ambulate and perform physical therapy Hayes J after EI ambulate and perform physical therapy 6

rehab (3 in room, tredmill) Passive and active exercises at the bedside and out of bed Active and passive PT, ambulate 2/4 tracheostomy NIV Norwood Hospital, Norwood, MA Hayes J 202 4 after EI 23 34

Ambulatory venovenous extracorporeal respiratory support as a bridge for cystic fibrosis patients to emergent lung transplantation.

7 05/04/203 AMBULATORY ECMO- out of bed physiotherapy N DAYS O V-A PT PROGRAM RESPIRATION Turner Crit Care Med 20 3 age Stand, walk, exercise program Mangi JTCS 200 age 34 3 V-A axillary vein Ambulate Bipap to prevent atelectasis Garcia JTCS 20 Lowman JD Cardiopulmonary Physical Therapy Journal 202 Reeb, ICVTS (bridge,ards) 6 weaned from MV age 6 age ± pts active rehab (3 in room, tredmill) Passive and active exercises at the bedside and out of bed Active and passive PT, ambulate 2/4 tracheostomy NIV Norwood Hospital, Norwood, MA Hayes J after EI ambulate and perform physical therapy Patient ambulating on a treadmill while on single-venous ECMO. Don Hayes Jr., Jasleen Kukreja, Joseph D. Tobias, Hubert O. Ballard, Charles W. Hoopes. Ambulatory venovenous extracorporeal respiratory support as a bridge for cystic fibrosis patients to emergent lung transplantation. Journal of Cystic Fibrosis Volume, Issue, January 202, Pages The Ohio State University, Columbus, OH, USA University of California at San Francisco, San Francisco, CA, USA University of Kentucky, Lexington, KY, USA Lowman JD, Kirk TK, Clark DE. Physical Therapy Management of a Patient on Portable Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplation: A Case Report. Cardiopulmonary Physical Therapy Journal 202, 23 (): University of Alabama at Birmingham, Department of Physical Therapy, Birmingham, AL Duke University Hospital, Department of Physical and Occupational Therapy, Durham, NC 7

05/04/203 REHABILITATION FEASIBLE AND SAFE PT interventions,

portable ECMO (veno-venous ECMO) as a bridge to lung

Bleeding and decannulation are the major concerns when mobilizing

$76 patients with ALF refractory to conventional therapy PAY$ ! Integrity of ECMO cannula Monitoring ECMO flow Signs and

8 05/04/203 REHABILITATION FEASIBLE AND SAFE PT interventions, including outofbedmobility, can be safely provided to patient on portable ECMO (veno-venous ECMO) as a bridge to lung transplantation. Bleeding and decannulation are the major concerns when mobilizing patients on ECMO. 76 patients with ALF refractory to conventional therapy PAY ATTENTION TO CANNULA!! Integrity of ECMO cannula Monitoring ECMO flow Signs and symptoms of poor cardiac output Trombosis? Christof Schmid, Venovenous extracorporeal membrane oxygenation for acute lung failure in adults. The Journal of Heart and Lung Transplantation 202 University Medical Center, Regensburg, Germany 8

05/04/203 ECMO Turner Crit Care Med 20 Lowman JD CPTJ 202 Emolisi Risk of

HYPOVENTILATION ( /3) DERECRUITMENT LUNG FLOWS AND VOLUMES Dyspnea?

Ospedale Maggiore Policlinico Milano Airway clearence tecniques-chest pt is

infections Avoid need for intubation ( VILI VAP SEDATION) INTUBATION = Embed

FT ROLE OF NIV Addition of NIV ACTB (Active cycle of breathing technique)

Holland, Thorax 2003 Ventilator settings can enhance or hinder secretions

9 05/04/203 ECMO Turner Crit Care Med 20 Lowman JD CPTJ 202 Emolisi Risk of bleeding hemoptysis Dense secreations SUPINE POSITION ( FRC) CO2 SHIFT HYPOVENTILATION ( /3) DERECRUITMENT LUNG FLOWS AND VOLUMES Dyspnea? UNEFFECTIVE AIRWAY CLEARENCE ATELECTASIS Hayes J 202 Reeb, ICVTS 202 Fondazione Ospedale Maggiore Policlinico Milano Airway clearence tecniques-chest pt is integral to the management of William Chest 94 Prevent atelectasis and infections Avoid need for intubation ( VILI VAP SEDATION) INTUBATION = Embed secreations, reduce FT intervention During exacerbation need for NIV to assist FT ROLE OF NIV Addition of NIV ACTB (Active cycle of breathing technique) resulted in preserved inspiratory muscle strenght. It can safely be used. Holland, Thorax 2003 Ventilator settings can enhance or hinder secretions clearence (embed mucus or expell it). Volpe, Respir Care 2008 Kim, J Appl Physiol 986 Ntoumenopoulos, Resp Care 20 FBS - BLEEDING 9

05/04/203 CASE REPORT Fondazione Ospedale Maggiore Policlinico Milano PATIENT WOB RISPOSTA VENTILATORIA lung gas exchange FEMALE AGE 43 CYSTIC

WOB ECMO GAS FLOW BLOOD FLOW- FiO2 26. PNX, WORSENING, INCREASING HYPERCARBIA 29.

5-6 L/min, BLOOD FLOW 2.3-3.3, FiO2 50-00% Register the patient as high emergency on the TX waiting list.

4, P/F 6, HCO3-39 (RS FiO2 0.90 +ECMO) Airleaks trought chest tube. Muscles straight MRC 5.

breathing (alternating O 2 reservoir and NIV), able to eat, drink, talk and have psycological support.

10 05/04/203 CASE REPORT Fondazione Ospedale Maggiore Policlinico Milano PATIENT WOB RISPOSTA VENTILATORIA lung gas exchange FEMALE AGE 43 CYSTIC FIBROSIS INSULIN DEPENDANT DIABETES Pseudomonas aeruginosa, strenotrophomonas maltophilia OTLT, HOME NOCTURNAL NIV NIV PS PEEP FiO2 GAS EXCHENGE RR WOB ECMO GAS FLOW BLOOD FLOW- FiO2 26. PNX, WORSENING, INCREASING HYPERCARBIA 29. hospital Dyspnea, Tachipnea, HYPERCARBIA, ACIDOSIS non NIV respondent ECMO (FEMOROFEMORAL) AS BRIDGE TO LUNG TRANSPLANTATION GAS FLOW L/min, BLOOD FLOW , FiO % Register the patient as high emergency on the TX waiting list. RS, RR 24, Borg DISPNEA3, respiratory accessory muscles recruitment Cough and secretions thick and color brown. ABG 7.405, PaCO2 63.6, PaO2 6.4, P/F 6, HCO3-39 (RS FiO ECMO) Airleaks trought chest tube. Muscles straight MRC 5. Central apnea associated with oxygen desaturation in sleep, (nadir SpO2 75%) For the entire period of ECMO therapy, the patient was spontaneusly breathing (alternating O 2 reservoir and NIV), able to eat, drink, talk and have psycological support. She was able to practice physiotherapy twice a day everyday. GOAL PREVENT ATELECTASIS, INFECTIONS AND EI PREVENT DECONDITIONING - Bronchodilators - Heated umidification - NIV - Airway clearence with NIV assistance (autogenic drainage and cough) - Seated with bed in chair position minimum 6 h/day - Active exercises (Isometric and isotonic) with or without NIV according to spo2 and dyspnea (Borg scale) 0

05/04/203 GOAL PREVENT ATELECTASIS, INFECTIONS AND EI PREVENT

clearence with NIV assistance (autogenic drainage and cough) - Seated

and isotonic) with or without NIV according to spo2 and dispnea (Borg

support and NIV time application GAS FLOW 2.5-6 L/min, BLOOD FLOW 2.3-3.

ECMO was done in st postoperative day Extubation in 4 th postoperative

11 05/04/203 GOAL PREVENT ATELECTASIS, INFECTIONS AND EI PREVENT DECONDITIONING - Bronchodilators - Heated umidification - NIV - Airway clearence with NIV assistance (autogenic drainage and cough) - Seated with bed in chair position minimum 6 h/day - Active exercises (Isometric and isotonic) with or without NIV according to spo2 and dispnea (Borg scale) Respiratory deterioration, gas exchange worsening Increased ECMO support and NIV time application GAS FLOW L/min, BLOOD FLOW , FiO % After 2 days: DOUBLE LUNG TRANSPLANTATION Weaning from ECMO was done in st postoperative day Extubation in 4 th postoperative day Postoperative course was complicated by renal insufficiency Discharge at home 2 month after TX

$05/04/203 IN CONCLUSION Awake vs intubation ECMO as bridge to lung transplantation vv ecmo is feasible in patients with isolated and refractory respiratory failure Avoid muscle deconditioning and MV$

12 05/04/203 IN CONCLUSION Awake vs intubation ECMO as bridge to lung transplantation vv ecmo is feasible in patients with isolated and refractory respiratory failure Avoid muscle deconditioning and MV Importance of FT, active reabilitation and ambulatory waiting for lung transplant active reabilitation can be safely provided in an ECMO pt (Attention to cannula!) Importance of airway clearence tecniques, that requires patients cooperation, in order to avoid FBS and intubation Role of NIV Lack of evidance and need for further invetigations 2

ECLS as Bridge to Transplant

ECLS as Bridge to Transplant Marcelo Cypel MD, MSc Assistant Professor of Surgery Division of Thoracic Surgery Toronto General Hospital University of Toronto Application of ECLS Bridge to lung recovery