ECMO/ECCO 2 R in Acute Respiratory Failure

Transcription

1 ECMO/ECCO 2 R in Acute Respiratory Failure Alain Combes, MD, PhD, Hôpital Pitié-Salpêtrière, AP-HP Inserm UMRS 1166, ican, Institute of Cardiometabolism and Nutrition Sorbonne Pierre et Marie Curie University, Paris, France alain.combes@aphp.fr

2 Conflict of interest Principal Investigator: EOLIA trial VV ECMO in ARDS NCT Sponsored by MAQUET, Getinge Group Received honoraria for lectures from MAQUET, XENIOS, BAXTER

3 ECMO and ECCO 2 R To decrease the intensity of MV?

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5 LUNG SAFE Epidemiology of ARDS

6 Probability of hospital survival by driving pressure

7 The evolving paradigm ARDSnet strategy might not protect against tidal hyperinflation When Pplat remains >28-30 cm H 2 O Further decrease of Vt to reduce VILI From 6 to <2 ml/kg IBW To decrease Pplat <25 cm H 2 O To decrease P < cm H 2 O With sufficient PEEP to prevent lung derecruitment Extracorporeal gas exchange for Blood Oxygenation/Decarboxylation Decrease the intensity of MV

8 What are ECMO and ECCO R? 2 Same Technology Different Objectives

9 Membrane lung O2/CO2 transfer ECMO for oxygenation ECCO2R for Decarboxylation CO 2 transfer O 2 transfer

10 Influence of ECMO flow PaO2 mmhg SaO2, % Adequate Oxygenation Qecmo > 60% Qco PaCO2 mmhg Schmidt et al, Intensive Care Med, 2013

11 PaO2 (mmhg) PaCO2 (mmhg) PASP (mmhg) PASP PaO2 (mmhg) PaO2 PaCO2 (mmhg) P < P < Influence of Sweep Gas Flow 110 PaO2 mmhg P Sweep < gas flow (L.min -1 ) PASP (mmhg) PaO2 (mmhg) P < PAPS mmhg Sweep gas flow (L.min -1 ) 110 Schmidt et al, Intensive Care Med, 2013 PASP (mmhg) PaO2 (mmhg) P < PaCO2 mmhg Sweep gas flow (L.min -1 )

12 ECMO and ECCO2R ECMO Large cannulas High extracorporeal flow >5000 ml/min Large membrane oxygenator Full blood oxygenation Full blood decarboxylation High technicity, ECMO center ECCO2R Double lumen catheter Low flow, respiratory dialysis ml/min Medium size oxygenator No blood oxygenation Partial blood decarboxylation Regular ICU

13 ECMO and ECCO 2 R What is the Evidence?

14 Results of series of VV-ECMO in ARDS patients

15 The CESAR trial

16 UK, ECMO provided only at the Glenfield Hospital, Leicester Entry criteria: Adult patients (18-65 years) Severe, but potentially reversible ARDS Murray score 3.0, or Uncompensated hypercapnia: ph <7.20 Primary outcome measure Death or severe disability 6 months

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20 Time from randomization to death Log rank p = 0.03

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27 17 (25%)

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31 The French REVA Registry collected data of patients hospitalized in ICUs For H1N1-associated ARDS Analysis of factors associated With death among 123 patients who received ECMO Case-control study with Matching on a propensity score to receive ECMO

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33 Why early ECMO?

34 1 P <0.005, log-rank MV <7 days before ECMO MV >7 days before ECMO

35 30 Before ECMO After ECMO Driving Pressure Tidal Volume Plateau Pressure

36 Results ECCO R series 2 in ARDS patients

37 Randomised clinical trial of pressurecontrolled inverse ratio ventilation and ECCO 2 R for ARDS Study design Randomised controlled clinical trial 40 patients with severe ARDS ECCO 2 R versus MV Low-flow veno-venous ECCO R 2 device Results No significant difference in survival at 30 days (p = 0.08): 42% in the MV group (n = 19) 33% in the ECCO 2 R patients (n = 21) All deaths occurred within 30 days of randomization Study stopped for futility >30% patients with severe haemorrhage Morris AH, et al. Am J Respir Crit Care 1994;349:

38 Techniques of the 2000 s

39 Novalung, ILA, Pumpless AV shunt

40 Novalung, ILA pumpless AV shunt

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45 Frequency of complications and adverse effects Complication / side effect Patients (n) Limb ischemia due to arterial cannulation + need for IV norepinephrine Ischemia of lower limb after cannulation 9 Cannula thrombosis 4 Compartmental syndrome in a lower limb 4 Haematoma / aneurysm at cannulation site 2 Haemolysis 1 Intracerebral haemorrhage 1 Diffuse bleeding / shock syndrome during cannulation 1 All 22 (24.4%) Overall frequency of complications and side effects was 24%

46 Hemodec DECAP

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48 Individual and average (horizontal bar) respiratory variables before and after initiating CO 2 removal V T (ml/kg PBW) P plat (cm H 2 O) PEEP (cm H 2 O) PaO 2 / FiO 2 )

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50 Techniques of the 2010 s

51 NOVALUNG

52 ila activve, Novalung, ILA membrane 22 French double lumen cannula Ten patients hypercapnic respiratory failure Step 1: Sweep gas flow increased from 1 to 14 L/min At constant blood flow Step 2: Blood flow gradually increased at constant sweep gas flow At each step measurement of Arterial blood gas AND Membrane gas transfer

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54 Hemolung, Alung Technologies

55 Feasibility and safety of low-flow extracorporeal carbon dioxide removal to facilitate ultra-protective ventilation in patients with moderate ARDS

56 Feasibility and safety of low-flow extracorporeal carbon dioxide removal to facilitate ultra-protective ventilation in patients with moderate ARDS Time course of C RS Time course of driving pressure

57 PALP, MAQUET

58 PrismaLung (Baxter)

59 Anesth Crit Care Pain Med 2014 Mean CO 2 removal rates at F s O 2 1 Preclinical study in 5 adult hypercapnic pigs to investigate the performance of the PrismaLung system with different flow rates (blood flow/ sweep gas flow)

60 More to come

61 A new paradigm

62 Increasing Intensity of Intervention ECMO Inhaled NO Neuromuscular Blockade Prone Positioning ECCO 2 R HFOV NIV Higher PEEP Low-Moderate PEEP Low Tidal Volume Ventilation Mild ARDS Moderate ARDS Severe ARDS The ARDS Definition Taskforce. JAMA 2012;307: PaO 2 /FiO 2

63 In God we (may) trust; all others must bring data W. Edwards Deming ( )

64 We need EOLIA A new trial of ECMO for severe pneumonia/ards 241 patients randomized so far YES WE CAN

65 A Strategy of UltraProtective lung ventilation With Extracorporeal CO 2 Removal for New-Onset moderate to severe ARDS The SUPERNOVA trial

66 Conclusion ECMO/ECCO2R: Potential for use in moderate to severe ARDS patients To allow further reduction of Vt/Pplat/ P, to limit VILI ExtraCorporeal CO 2 Removal Respiratory dialysis for moderate ARDS VV-ECMO For refractory hypoxemia For severe ARDS? Before large diffusion, (re)test the concept in large randomized clinical trials

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