Ventilator ECMO Interactions Lorenzo Del Sorbo, MD CCCF Toronto, October 2 nd 2017
Disclosure Relevant relationships with commercial entities: none Potential for conflicts within this presentation: none
ICU VENTILATOR Oxygenation CO 2 clearance Survival? Del Sorbo et al. Lancet Resp Med. 2014
Fan E et al.am J Respir Crit Care Med. 2017
Brodie D and Bacchetta M, NEJM 2011
Adult respiratory ECMO: mortality rate 55% Controversial issues in the management of ECMO: -. -Mechanical ventilation strategies
AJRCCM 2013
Multivariate analysis age (OR 1.09; 95% CI: 1.04 1.15; P < 0.01) lactate under ECMO (OR 1.42; 95% CI: 1.18 1.82; P < 0.01) higher Pplat first day on ECMO (OR 1.33; 95% CI: 1.14 1.59; P < 0.01) were the only three variables significantly associated with ICU death Pham et al. Am J Respir Crit Care Med. 2013
Intensive Care Med (2016) 42:1672 1684
Design: Retrospective observational study Setting: Three international high-volume ECMO centers Patients: 168 patients on VV-ECMO for ARDS Crit Care Med 2015
VENTILATOR ECMO interactions Diverse ventilatory strategies during VV-ECMO
ELSO Guidelines Ventilator management The goal of ventilator management on ECLS is to use FiO2 <0.4, and non-damaging rest settings Pressure controlled ventilation at 25-15, I:E 2:1, rate 5, FiO2 50%, FiN2 50% Positive pressure is continued to maintain some lung inflation, but PPlat over 25 can cause ongoing lung damage PEEP can be as high as tolerated
VENTILATOR VV-ECMO interactions Pathophysiological considerations
The role of mechanical ventilation during VV-ECMO: pathophysiological considerations - 1 No response to conventional approaches (RM, prone positioning, high PEEP) VV-ECMO High susceptibility to VILI (baby lung) Del Sorbo et al Minerva Anest. 2014
N Engl J Med 2013;369:2126-36.
The role of mechanical ventilation during VV-ECMO: pathophysiological considerations - 2 ICU VENTILATOR MV is not absolutely necessary during VV-ECMO to facilitate gas exchange Del Sorbo et al Lancet, Resp Med. 2014
The role of mechanical ventilation during VV-ECMO: pathophysiological considerations - 3 ICU VENTILATOR During VV-ECMO lung is perfused with oxygenated blood Del Sorbo et al Lancet, Resp Med. 2014
The role of mechanical ventilation during VV-ECMO: pathophysiological considerations Improving Gas Exchange Mechanical Ventilation VILI Del Sorbo et al Minerva Anest. 2014
The role of mechanical ventilation during VV-ECMO: pathophysiological considerations Improving Gas Exchange VILI VV-ECMO Del Sorbo et al Minerva Anest. 2014
VENTILATOR ECMO interactions What tidal volume?
Del Sorbo et al Minerva Anest. 2014
VENTILATOR ECMO interactions Spontaneous breathing?
Healthy sheep Sheep with ARDS
ICM. 2016
Cross-over study: PSV vs NAVA 8 Pts on VV-ECMO recovering from ARDS Anesthesiology 2016
Cross-over study: PSV vs NAVA 8 Pts on VV-ECMO recovering from ARDS Anesthesiology 2016
VENTILATOR ECMO interactions What PEEP?
Del Sorbo et al Minerva Anest. 2014
Suter, NEJM 1975
Del Sorbo et al Minerva Anest. 2014
Hypoxia induced lung inflammation Madjdpour C. Am J Physiol Lung Cell Mol Physiol, 2003
Veno-venous Extracorporeal Membrane Oxygenation Del Sorbo et al. Lancet Resp Med. 2014
Lungs of patients with acute respiratory distress syndrome show diffuse inflammation in normally aerated regions: A [18F]-fluoro-2- deoxy-d-glucose PET/CT study Bellani G.
Lobar pneumonia
Strategies for Optimal Lung Ventilation in ECMO for ARDS: The SOLVE ARDS study Extracorporeal gas exchange in ECMO allows us to separate the impact of inspiratory tidal volumes and end-expiratory lung volumes on VILI, which is technically more difficult in patients with severe ARDS who are supported solely with mechanical ventilation
Primary Hypotheses 1. Reducing tidal stress and strain to zero (by decreasing driving pressure/tidal volume) will mitigate VILI during VV-ECMO (tested in Phase 1) 1. Reducing tidal strain (by adjusting end-expiratory pressure to maximize compliance) will mitigate VILI during VV-ECMO (tested in Phase 2)
Secondary Objectives To evaluate effects of changing driving pressure and end-expiratory pressure on: RV function Lung ultrasound abnormalities
VENTILATOR ECMO interactions VV-ECMO as alternative to MV?
ECMO as alternative to MV in ARDS:? Hoeper MM et al. ICM. 2013
32-year-old woman with advanced cystic fibrosis lung disease
Conclusions Ventilator ECMO interactions -May impact survival -Diverse ventilatory strategies -Different risk/benefit profile of MV (high risk of VILI) -On-going effort to identify the best conditions to facilitate lung protection/healing (i.e. The SOLVE ARDS study) -VV-ECMO as alternative to MV??
lorenzo.delsorbo@uhn.ca Thank you!