Roberto Fumagalli Ospedale Niguarda Ca Granda Universit degli
Studi Milano Bicocca Milano Disclosure: none Management of native
lung on ECMO
Slide 2
Slide 3
The Oxygenator in Venovenous ECMO. Brodie D, Bacchetta M. N
Engl J Med 2011;365:1905-1914
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OXYGENATION FiO 2 =1.0 250 mL min -1 VO 2 250 mL min -1 Sat a
98% P a O 2 110 mmHg Hb 15 g Sat v 82% 7000 mL min -1 PBF CO 2
REMOVAL VA 2-4 L min -1 VCO 2 200 mL min -1 CO 2 cont 34 mL P a CO
2 15 mmHg P v O 2 47 mmHg CO 2 cont 52 mL P v CO 2 43 mmHg 1100 mL
min -1 PBF Gattinoni et al., European Advances in Intensive Care,
1983; 21: 97-117
Minute ventilation was then reduced by adjusting frequency and
inspiratory pressure. PEEP was increased to ventilate the patient
with the least possible mechanical stress while maintaining a
sufficient level of oxygenation (oxygen saturation by pulse
oximetry [SpO2] 90%).
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Ventilator settings were reduced to rest settings as soon as
possible after transport to Stockholm and when stable on by-pass.
Peak inspiratory pressures were adjusted to 20-25 cm H20, PEEP5-10
cm H20 and FiO2 0.4.
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Non Recruiter strategy In 33 patients (49%), a second access
cannula was needed to augment ECMO support.
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Non Recruiter strategy Low PEEP (5-10) LPS PSV High Blood Flow
II drainage cannula NO PNX Pulmonary Hypertension V-A bypass?
B.F.
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Recruiter strategy RMs PEEP Titration SIGH PNX ?
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% Opening and closing pressures 50 Opening pressure Closing
pressure Paw > 35 cmH 2 O to fully recruit 05 40 30 20 10 0 10
15 20 25 30 35 40 45 50 Paw [cmH 2 O] Crotti et al. Am J Respir
Crit Care Med 2001
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Modern PEEP Titration 10 12 15 7 10
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Sigh ( 1 ogni 3 min ) Effects of periodic lung recruitment
maneuvers on gas exchange and respiratory mechanics in mechanically
ventilated ARDS patients. G. Foti, M.Cereda, M.E. Sparacino, L. De
Marchi,F. Villa, A. Pesenti Intensive Care Med (2000) 26: 501-507
Pressione di reclutamento Oxygenation Qva/Qt SIGH
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Always keeping in mind that Packer et al Crit Care Med
1993;31:131-143
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FRC V E (L/min) RATIO NORMAL ARDS 250072.8 5001224 SPECIFIC
HYPERVENTILATION
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Hager DN AmJ Respir Crit Care Med :2005: 172: 1241
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Normal sheeps randomly assigned to 3 groups: A: control MV 48
hrs B: PIP 50 cm H 2 O RR 1-3 bpm C: PIP 50 cm H 2 O RR 12 bpm CO 2
3.8 Kolobow T, Moretti MP, Fumagalli R et al Am Rev Resp Dis 1987,
135: 312-315
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Group AGroup BGroup C Normal5-- Light damage 1-- Moderate211
Severe-1- Very severe-58 Kolobow T, Moretti MP, Fumagalli R et al
Am Rev Resp Dis 1987, 135: 312-315
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Spontaneous breathing in ARDS spontaneous breathingcontrolled
ventilation, NMBA
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Control of breathing using an extracorporeal membrane lung The
lung rest concept Kolobow T, Gattinoni et al., Anesthesiology,
1977; 46: 138-141
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The most appropriate ventilator settings for patients with
severe ARDS who are undergoing ECMO are unknown.
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Whenever possible, we aim for limitation of pressure and set
respiratory rates that are at least as restrictive as those
described above, along with tidal volumes that are typically main-
tained below 4 ml per kilogram of predicted body weight, to
minimize the potential for ventilator- associated lung injury.
Whatever the approach, applying adequate PEEP is important to
maintain airway patency at the low lung volumes attained with these
settings.
