Pro: Early use of VV ECMO for ARDS Kyle J. Rehder, MD, FCCP Associate Professor Division of Pediatric Critical Care Medicine Department of Pediatrics Duke Children s Hospital
The ventilator is slowly killing your ARDS patient: Early V-V ECMO saves lives! Kyle J. Rehder, MD, FCCP Associate Professor Division of Pediatric Critical Care Medicine Department of Pediatrics Duke Children s Hospital
Disclosures! Clinical consultant for McKesson Health Solutions! Uses of ECMO in this talk are off-label! Any photos are not meant to endorse the use of a specific product
Why early ECMO?! ARDS remains a problem! We must protect the lungs! Despite new techniques and modes of ventilatory support, outcomes remain poor
ARDS: A clinical challenge! ARDS disease burden remains high Common cause of ICU admission 30% mortality 1 Significant morbidity in survivors! VILI is an important consideration ALI often develops after initiation of mechanical ventilation 2 1 Mercat, JAMA, 2008 2 Gajic, Crit Care Med, 2004
VILI in healthy lungs Gajic, Crit Care Med, 2004
Lung Protection = Survival 6 ml/kg 12 ml/kg ARDSnet, NEJM, 2000
Other Ventilator Strategies?! HFOV 1! APRV 2! Perflubron 3! Novel vent modes 4 Neurally Adjusted Ventilatory Assist (NAVA) Proportional Assist Ventilation (PAV) Adaptive Support Ventilation (ASV) 1 Sun, BMJ, 2010 2 Maxwell, J Trauma, 2010 3 Hirschl, AJRCCM, 2002 4 Turner, Exp Rev Resp Med, 2012
Ancillary Therapies?! Steroids 1! Neuromuscular blockers 2! Nitric Oxide 3! Surfactant 4! Prone positioning 5,6 1 Peter, BMJ, 2008 2 Alhazzani, Crit Care, 2013 2 Afshari, Cochrane Rev, 2010 4 Willson, PCCM, 2013 5 Guerin, NEJM, 2013 5 Curley, JAMA, 2005
ARDS outcomes unchanged ARDSnet 1 Low V t Survival: 69% Study Study Group Control Survival OSCILLATE 2 HFOV 65% OSCAR 3 HFOV 59% ACURASYS 4 NMB 58% Prone Position 5 Prone 59% Meta-Analysis 6 HFOV 51% 1 ARDSnet, NEJM, 2000 2 Ferguson, NEJM, 2013 3 Young, NEJM, 2013 4 Papazian, NEJM, 2010 5 Guerin, NEJM, 2013 6 Sun, BMJ, 2010
What About Pediatrics? Study N Survival Flori AJRCCM 2005 166 74% Khemani ICM 2009 398 80% Lopez Fernandez CCM 2012 146 74% De Luca ICM 2013 185 81% Khemani ICM 2015 129 67% Mortality increases with severity of lung injury
Peds ARDS outcomes Overall survival: 67% P/F 100 survival: 47% Khemani, ICM, 2015
ECMO Outcomes Peds severe ARDS survival rate <50% Peds survival 57% Adult survival 57% ELSO Registry, January 2015
ECMO is becoming easier and safer! Consistent survival over time: Comorbidities increased 19% to 47%! Patients with no comorbidities: Survival increased 57% to 72%! Reduced mechanical complications over time Associated with improved survival Zabrocki, PCCM, 2012 Fleming, PCCM, 2009 Sivarajan, CV Thorac Surg, 2010
ECMO is easier and safer than ever! Improved ECMO technology - cannula (adult double lumen VV) - oxygenators, circuitry - pumps! Improved ECMO strategies! Increased simplicity/portability of circuits - Cardiohelp system - Awake ECMO
Early ECMO saves lives! Lung Rest Avoids VILI Allows lung recovery! Improves oxygen delivery for other organs! Allows patients to be more awake? Decreases neurologic morbidity
CESAR Trial Improved disability-free survival! RCT: 180 adults with severe respiratory failure! Referral to ECMO center vs. conventional strategy Peek, Lancet, 2009
CESAR: Early Mortality Peek, Lancet, 2009
H1N1: Early Mortality Noah, JAMA, 2011
Lung Tx: Early Mortality Awake ECMO Control Time from intubation or ECMO cannulation Fuehner T, Am J Resp Crit Care Med, 2012
Decreased survival after 14 days Every vent day prior to ECMO increases mortality by 2.9% Zabrocki, PCCM, 2012 Nance, J Peds Surg, 2009
We can predict ARDS outcome by 24 hours Mortality (rate) OI<4 OI 8-16 OI 4-8 OI >16 OI<4 OI 8-16 OI 4-8 OI >16 Yehya, CCM, 2015
No Longer a Rescue Therapy? Earlier ECMO may lead to better outcomes! Checkley, JAMA, 2012
Conclusions! Rescue ECMO outcomes are at least as good as conventional therapy! ECMO is safer than ever! ECMO avoids morbidities! VILI! Neurologic! Recovery days are lost on CMV
14 yo: Flu + MRSA
Case: A 41 year old woman is intubated and MV is initiated with a volume- and pressure-limited approach for ARDS. Over the ensuing 24 hours, her PaO2 decreases and does not improve with NMB and prone positioning. Recommendation: Venovenous ECMO.
Audience Response Previously healthy 16yo F admitted to ICU with severe pneumonia. She requires intubation 6 hrs after admission. Her status steadily declines; at 12 hrs her P/F ratio is 65 with PEEP of 10 cmh2o and Pplat 28 cmh2o. She is hemodynamically stable with normal renal function. Your next step? a) Increase PEEP b) Prone positioning c) Inhaled vasodilators (epoprostenol or nitric oxide) d) ECMO e) HFOV
Questions? kyle.rehder@duke.edu
Cost Effective?! ECMO referral: Base cost: $122K (vs. $55K control) 0.03 QALY gained @ 6 months! Cost-utility analysis Cost of QALY gained: $31K Below threshold $33K Peek, Lancet, 2009
Maybe the MICU is figuring out what we already knew 1989 2 runs 2014 1497 + runs ELSO Registry, January 2015
Rehabilitation may improve post-transplant outcomes