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Updates in Support of

Respiratory Failure and Ecmo

Stephen J Fitch MD FCCP FAASM

Medical Director of Medical

Intensive Care and Adult Ecmo

Spectrum Health

Grand Rapids, MI

June 2, 2017

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Learning Objectives

Understand Evolving/Continuing Concepts in Vent support

Understand the importance of ICU Liberation in Vent support

and ICU Survival

Understand the Evolving role of Ecmo in support of various

types of respiratory and cardiac failure

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Overview

Support of Respiratory Failure

NIPPV

NIPPV post extubation

ARDS

Prone position ventilation

Esopogeal Monitoring

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Overview (cont)

Ecmo

Initiation and weaning

Multidisciplinary Discussion

Intra/Post op Ecmo

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Overview

ICU Liberation

Purpose of Vent Support

Despite new technology and increased

bells and whistles:

1- Goal remains provide gas exchange

support for failing lung without injury

2- Minimize time this is required to

minimize deconditioning, delirium and

debility8

NIPPV

Significant aid in support of patients

Better understanding of its role

Not just the thing you do before intubating

Important to understand where helpful,

and where probably not

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NIPPV

Best for situations where underlying

problem can turn around quickly (CHF,

Diastolic dysfunction, asthma/COPD

exacerbation

Suboptimal for situation that take longer

(pneumonia with respiratory failure,

evolving ARDS, poor airway protection)10

NIPPV

Underutilized as a bridge to Vent liberation

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NIPPV

Identified patients with high risk of

reintubation (> 20% likelihood)

Ventilation > 24 hours

Age > 65

Presence of cardiac or respiratory

disease (acute or chronic)12

NIPPV

Intervention group had one hour periods of

BiPAP (8/5) for at least 8 hours for first

24 hours.

Reassessed daily and stopped once no

further evidence of resp failure

End point was reintubation at 7 days

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NIPPV

In the high risk group, reduction of

reintubation from 28% to 15% after

intervention protocol

Implications not only related to

reintubation, but may help us be more

aggressive about extubation.

Reintubation rates often low in many ICUs14

NIPPV

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NIPPV

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ARDS therapy

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ARDS Therapy

A little over 17 years since this study, many

institutions struggle to implement these important

concepts

Several studies have demonstrated poor

compliance with 6 ml/kg tidal volume, even in

ARDS studies!1

Reasons: Lack of recognition, Changing lung

compliance, Spontaneous breathing, ICU

Liberation18

ARDS Therapy

Important to monitor and adjust vent

support to maintain these important

parameters

Recording ml/kg with vent checks

Development of Quality Metrics around

this

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ARDS Therapy

Prone Position Ventilation

Originally shown to be beneficial more than 15

years ago 2

Variable benefit in trials subsequently

timing

patient selection

study design20

ARDS Therapy

Prone Position Ventilation

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ARDS Therapy

Proseva

Multicenter Trial

446 patients

Randomized to 16 hours prone or remain

supine

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ARDS Therapy

Proseva

ARDS Definition

PaO2/FiO2 < 150

FiO2 .6 or greater

PEEP 5 or greater

Vt 6 ml/kg23

ARDS Therapy

Proseva

237 prone 229 supine

28 day mortality- 16% prone, 33% supine

Complications similar

First Multicenter, randomized proning trial

to show mortality benefit24

ARDS Therapy

Esophageal Pressure Monitoring (EPM)

Technique to optimize PEEP and account for

extrapleural pressure (chest wall, abdominal,

subcutaneous!)

Respiratory system compliance is combination of

pulmonary compliance plus all these adjacent

structures

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ARDS Therapy

EPM

Transpulmonary Pressure = airway

pressure – esophageal pressure

Measured during end inspiratory or

expiratory occlusion

Represents pressure to distend the lung

parenchyma26

ARDS Therapy

EPM

Especially useful in obesity but also in cases

of hemothorax or abd hypertension

Emerging data on more routine use

Suggestion that chest wall compliance may

be common problem in critical illness

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ARDS Therapy

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ARDS Therapy

When Pes is used in conjunction with inspiratory

hold, can give a more accurate idea of true Ppl

29 British Columbia Resp Ther

ARDS Therapy

When used in conjunction with expiratory hold can tell us

whether PEEP adequate to prevent derecruitment

30 British Columbia Resp Ther

ARDS Therapy

EPM Case

51 yo WM transferred from outside hospital for hypoxemic

resp failure unable to be supported. Transfer for Ecmo

consideration. 211 kg (BMI 78)

Initial setting on transport PIP 18 giving Vt 500 (6ml/kg

based on PBW of 73 kg- 440 ml), rate 20, PEEP 16, FiO2

1.0. Sats in 80’s on arrival. Sedated and paralyzed.

EPM placed. Ptp -16! PEEP increased to 30 cwp and Ptp 0

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ARDS Therapy

EPM Case

Repeat ABG with PO2 134

And…

Inspiratory pressure decreased to 10 cwp

to get Vt of 450

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Ecmo

Evolving role. Still quite limited data.

Still quite limited to specific centers

Remains labor intensive and specialty skill intensive

Definitely has important role in support of the

sickest patients

We encourage early discussion with our referring

partners to ensure appropriateness and timing

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Program Volume – CY 2016

* Volume based on number of runs, some patients may have had more than one

Ecmo

Veno-arterial support for cardiac disease

Continues to comprise majority of our

cases

Increasing use of somewhat less invasive

devices like Impella

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Ecmo

VA for cardiac support

Implemented a decision making protocol

Purposeful discussion about goals for

and options after Ecmo during

multidisciplinary shock call

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Ecmo

VA for Cardiac Support

Implemented a specific weaning protocol

Intent to highlight that VA Ecmo should

be viewed as a short term therapy

Recovery, Palliation, Long term device

Have specific conversation in first days37

Ecmo

VA for Cardiac Support

ECPR

Labor intensive

Worst Outcomes

Difficult to deliver symmetrically38

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Survival by ECMO Mode – CY 2016

Patient 1:

LOS: 273 days

Charges:

$3,335,376

Disposition:

DC to CAR,

cognitively intact.

Cardiac arrest,

expired 10 days after

DC from MHC.

=

Patient 2:

LOS: 13 days

Charges:

$274, 235

Disposition:

DC to CAR,

some concern of

anoxic injury.

A&O x4 at time of

DC from CAR.

Data source: Crimson and Cerner

Ecmo

VA Ecmo for Cardiac Support

Predictions much more difficult for VA

Especially so for ECPR

Have developed some fairly restrictive

criteria for ECPR use

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Ecmo

Post Op VA Ecmo

Historically verboten due to poor survival

Implication was something went horribly wrong

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Ecmo

Post Op VA Ecmo

Evolving thinking:

High risk surgeries (Elderly, redo, both, both plus

comorbidities, transplant)

If we are going to take on high risk cases,

probably unreasonable to think they will sail

through

Allows time to recover 42

VA Patient Breakdown

Cannulation Reason:

■ Intra/Post-op: 54% (40/74)

■ Shock: 46% (34/74)

Survival

■ Intra/Post-op: 70% (28/40)

■ Shock: 53% (18/34)

Turns out they do quite well43

Ecmo

Venovenous Support

Looking to optimize time of initiation

Ensure we have exhausted other therapies

Yet, outcomes seem better with earlier

initiation3

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Ecmo

Venovenous Support

Very low tidal volume with PEEP

Try to minimize sedation

Mobility if possible

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ICU Liberation

ABCDEF Bundle

Control of Pain

Reduction of Delirium

Liberation from ventilation

Restoration of physical strength

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ICU Liberation

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Critical Care Medicine Feb 2017 vol 45 no 2

ICU Liberation

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ICU Liberation

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ICU Liberation Collaborative

Vanderbilt University led Initiative with 77 ICUs

Designed to understand how teams are implementing this

care

Share experiences, develop new approaches

ICU Liberation

Truly Culture Change

Multidisciplinary

Requires Champions (especially physicians)

Changes are scary and anxiety provoking for staff

Ultimately, some of the most important work we can

do over the next decade!

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Conclusion

Leading edge work at present involves a

combination of ways to get the very sickest

patients better while minimizing the carnage that

comes from delivering that care and recovering

from those illnesses.

How we approach that dichotomy will determine

how far we can push the envelope of healing…

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Questions?

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References

1) Poole, et al. Br J Anaesth (2017) 118 (4): 570-575

2) Gattinoni, et al N Engl J Med 2001;345:568-73

3) Peek, et al Lancet 2009;374:1351-63

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