Respiratory ECMO

Sachin ShahAdult Intensive Care UnitRoyal Brompton HospitalLondon

Disclosures

Objectives

• Respiratory ECMO service

• Referrals

• Practical aspects

• Case discussion

Respiratory ECMO Service

Single adult centre (Glenfield, Leicester) 1989-2011

H1N1 pandemic, temporary commissioning:

2009-10 3 extra centres (RBH, Papworth, Aberdeen)

2010-11 5 extra centres

2011 - contracts awarded to 5 hospitals in England

Geographical service - based on critical care networks

Referral criteria similar to CESAR study

Centres expected to collaborate to provide national service

ECLS in ICU

Modality PumpBlood flow

rate (l/min)Physiological effects

VA - ECMO Yes 4 - 6oxygenation, CO2 removal

cardiac support

VV - ECMO Yes 2 - 6 oxygenation & CO2 removal

AV - ECCO2R

‘Novalung’No 0.7 - 1.5 partial CO2 removal

VV - ECCO2R Yes 0.2 - 0.5 partial CO2 removal

Technical

difficulty

Rescue therapies

Development of ECMO

1967 Description of ARDS

Ashbaugh

1970 Injured lungs susceptible to over-distension (VALI)

Mead

1972 First successful ECMO in adult ARDS patient

Hill

1979 RCT of ECMO for adult ARDSZapol

1990s Positive UK collaborative RCT - neonatal ECMO

Adult case series - enthusiastic centres

Rationale for vv ECMO

Maintain oxygen deliveryPatients with severe hypoxamia

Control respiratory acidosisPatients with severe hypercarbia

Lung protective ventilation (rest settings)Decrease FiO2

Decrease Vt, Paw and respiratory rate

Improved haemodynamic stability

Buy timeTreatment of primary disease

Optimisation of supportive care

Indications

WythenshaweGlenfieldPapworthGSTTRoyal Brompton

London

NHS England adult respiratory ECMO centres

• Minimum 20 adult cases per year

• ECMO units must have

– capability for ECMO retrieval

– based in a cardiothoracic hospital

– provide surge capacity

– ability to provide all modes of advanced respiratory support

– clear referral & repatriation networks

• Joint audit & service development

• Service started on December 1st 2011

UK ECMO Commissioning

UK H1N1 ECMO service 2009-10

3 additional ECMO centres commissioned

Royal Brompton, London

Papworth, Cambridge

Aberdeen, Scotland

Royal Brompton H1N1 experience

20 adult patients referred for ECMO and

admitted

10 patients managed with ECMO

80% overall survival to home

http://www.elso.med.umich.edu/

ELSO

160 member institutions

Multidisciplinary

ECLS registry: > 40,000 cases

Meetings

Education

Support research & regulatory agencies

http://www.elso.med.umich.edu/

ASAIO Journal 2013;59:202–210

Adult Respiratory Outcomes - ELSO

Overall survival: 55% 2011 - 58%

Evidence for ECMO in severe acute respiratory failure

• Many case series

• One older randomised controlled trial (1970s)

• One recent randomised controlled trial (CESAR)

• One recent cohort study (H1N1)

• Randomised controlled trial currently underway (EOLIA, NCT01470703) – due 2015

The first randomised controlled trial of ECMO for severe acute respiratory failure

Zapol et al. JAMA 1979; 242: 2193-96

Inclusion criteriaPaO2 <50mmHg on fiO2 1.0 for 2 hours and PEEP ≥5cmH2O

or PaO2 <50mmHg on fiO2 0.6 for 12 hours and PEEP ≥ 5cmH2O

Exclusion criteriaAge <12 or >65 years

Duration of pulmonary insult > 21 daysPulmonary capillary wedge pressure > 25mmHg

Chronic or irreversible systemic disease

ECMO therapyNine centres

Veno-arterial bypass

Cessation of ECMO supportPaO2 ≥70mmHg on FiO2 0.6, PEEP 5cmH2O, ECMO flow 0.5L/min for 6 hours

Technical complications, excessive bleedingNo improvement after 5 days ECMO

Results

• 90 patients randomised to veno-arterial (VA) ECMO or conventional management

• 4 survivors in each group

Zapol et al. JAMA 1979; 242: 2193-96

Why was outcome so poor?

• Inexperienced centres (<5 patients treated at each centre)

• VA (not VV) ECMO

• Excessive bleeding

• Duration of ventilation pre-ECMO >9 days(7 of the 8 survivors ventilated <7 days)

• No lung rest

Zapol et al. JAMA 1979; 242: 2193-96

Potential effects of high volume and high pressure ventilation

Fu et al. J Appl Physiol 1992; 73: 123-33

PneumothoracesPneumomediastinumSubcutaneous air

Rupture of alveolar capillaries

ARDSnet ARMA trial

• 861 patients with ARDS

• Randomised to tidal volume 6ml/kg vs 12ml/kg PBW

• Actual tidal volume 6.2±0.8 vs 11.8±0.8 ml/kg PBW

• Actual Pplat 25±6 vs 33±8 cmH2O

First 50 adult ECMO patients at Glenfield Hospital

• 1989 to 1995, veno-venous ECMO

• ‘Lung rest’• Peak inspiratory pressure 20cmH2O

• PEEP 10cmH2O

• Rate 10 breaths/min

• FiO2 0.3

• Survival to hospital discharge 66%

• Mean duration of ECMO support >8 days

• Improved survival compared with historical controls

Peek et al. Chest 1997; 112: 759-764

Other case series of ECMO in ARDS

Author

(location)

Reference Years n Diagnoses Outcome

Peek

(Leicester)

Chest 1997; 112: 759-64 1989-1995 50 Pneumonia and ARDS 66% hospital discharge

Lewandowski

(Berlin)

Intensive Care Medicine 1997;

23: 819-835

1989-1995 49 ARDS 55% ICU survival

Ullrich

(Vienna)

Anaesthesiology 1999; 91:

1577-86

1995-1997 13 ARDS 62% ICU survival

Kolla

(Ann Arbor)

Ann Surg 1997; 226: 544-64 1990-1996 100 Pneumonia and ARDS 54% hospital survival

Frenckner

(Stockholm)

Minerva Anestesiol 2002; 86:

381-6

1995-2002 38 Respiratory failure

(mainly pneumonia)

66% 30d survival

Hemmila

(Ann Arbor)

Ann Surg 2004; 240: 595-607 1989-2003 255 Severe ARDS 52% hospital survival

What did we learn from case series?

• Survival of patients receiving VV ECMO improving

• Duration of ventilation pre-ECMO

• Age

• Bleeding/transfusion

• Cannot reach firm conclusions regarding efficacy of ECMO without RCT...

Conventional ventilatory support vs

ECMO for

Severe

Adult

Respiratory failure

71 % discharged home6 (8%) remained in patients

• 1972 – first report of successful use of extracorporeal circulation to treat acute hypoxaemia respiratory failure in an adult patient

Hill JD et al. J Thorac Cardiovasc Surg 1972; 64: 551-562

ECMO during CESAR

ECMO cart

ECMO - complications

HaemorrhageIntracranial (CESAR 4.5%, ANZ 9%)

Gastrointestinal

Nasal

Circuit problemsCircuit clotting

Circuit air

Motor failure

Cannulation problems

RBH activity 2014 – commissioned pathway

N

Referrals 159

AdmissionsECMO / ECCO2RVA ECMONovalungNo extracorporeal support

4339413

Patients not admittedFutility“Too well”Referrer wants to keepLack of capacity(transferred by RBH)

60136

284

Demographics

• Age 43 yrs mean Range 17-66 yrs

• Sex 55% male

Definitive microbiology diagnosis in 46% patients

Percentage Percentage on total Associated infections

Pneumococco 15% 7% - Influenza B 2%

Influenza A 15% 7% - Influenza B 2%

Legionella 11% 5%

PCP 8.7% 4% - HIV 75%- Staph aureus 25%

Pseudo aeruginasae 8.7% 4% - CF 50%

TB 8.7% 4%

Influenza B 8.7% 4% - MRSA 25%- MSSA 25%- Pneumococco 25%- Influenza A 25%

Staph aureus 8.7% (25% MRSA) 4%

E.Coli in BAL (aspiration

pneumonia)

2% 1%

Percentage Percentage on total Associated infections

Adenovirus 2% 1%

Coliforms in BAL 2% 1%

Human Metapneumovirus

2% 1%

K. pneumoniae in TA(aspiration

pneumonia)

2% 1%

Mycoplasma 2% 1%

PVL 2% 1%

RSV 2% 1%

VRE sepsis inaspiration

pneumonitis

2% 1%

Diagnosis with no positive microbiology in 54% patients

ECMO patients 2014

0

5

10

15

20

25

30

35

40

45

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

Dec

-14

Min

ECMO

ECMO bed-days

0

100

200

300

400

500

600

700

800

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Cu

mu

lati

ve b

ed

day

s o

n N

HSE

pat

hw

ay

Beds used

+ 480 standard bed days

Retrievals2013-14 2014

Retrievals 37 40

Median distance round trip, miles 32 75

Total distance, miles 3978 5230

Mobile ECMOMobile VA ECMO

24 352

Plus 9 retrievals for non-NHSE ECMO pathway:

2014

Retrievals 9

Median distance round trip, miles 28

Total distance, miles 1621

Mobile ECMOMobile VA ECMO

53

Referrals

http://www.rbht.nhs.uk/healthprofessionals/clinical-departments/critical-care/ecmo/

Management at local hospital

• Haemodynamically stable

• Cardiac output monitoring

• Echo

• Consider proning

• Fluid management

Preparing for retrieval

• Checking equipment

• Call team (ECMO consultant, perfusionist, ECMO fellow)

• Call ambulance

• Communication

Preparation locally

• Next of Kin

• At-least two units packed cells cross matched and available

• Imaging transfer (IEP)/CD’s

• Anaesthetic Team

• Transfer patient on ICU ventilator

• Theatre space with scrub nurse

• Radiographer with image intensifier

Theatre preparation

• Standard trolley

• Fenestrated drape used for central cannulation

• Total body drape

• Swabs

• Jug with normal saline

• Ultra-sound for central access

Returning

• Will carry cross matched blood with us

• Use your front line ambulance service

Guidance for ambulance

• Compatible with Stryker locking device fitted to LAS 5 series ambulances

• Vehicle with tail lift

• 240V power inverter with standard three pin UK plug

• Full oxygen supply

Summary

• ECMO referral pathway

• Evidence

• Logistic