ECMO: Thông khí nhân tạo Những vấn đề quan tâm Kenneth Lyn-Kew, MD

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ECMO:

Mechanical

Ventilation

Considerations

Kenneth Lyn-Kew, MD
National Jewish Health

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Goals

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Case



38yo male presents with 1 day of malaise and SOB



Pt intubated and has progressive respiratory failure



Pt on 5 cc/kg/IBW, PEEP 20, Pplat 34, FIO2 1.0 in

prone position

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What do you do next?



A) Paralyze him?

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VV-ECMO

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VV-ECMO



<b>ELSO Guidelines</b>

 <b>V-V</b> Indications

 Respiratory support-consider if mortality >50% and
recommended if mortality >80%

 ARDS/hypoxemic respiratory failure

 PaO2 to FiO2 ratio less than 80, despite salvage therapies
for 6+ hrs

 Uncompensated hypercapnia (ph<7.15 despite measures)

 Hypercapneic respiratory failure (severe COPD/asthma
exacerbation)

 Lung transplant candidates

 Severe air leak patients

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VV-ECMO



CESAR study inclusion criteria (Lancet 2009; 374:
1351–63).



Indications:

 age ≥16 years

 potentially reversible severe acute respiratory failure

 no limitation to on-going life-sustaining treatment

 Murray score ≥3.0 (consider referral if ≥2.5 and rapid
clinical deterioration) OR

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VV ECMO



<b>V-V</b> Contraindications

 No absolute contraindications but the following are
associated with a poor outcome

 Mechanical ventilation with high support (Fio2>90%
and/or P-plat >30 for 7 days)

 CNS hemorrhage

 Pharmacologic immunosuppression (ANC<400)

 Non-recoverable comorbidity

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VV-ECMO

Contraindications (CESAR):



intracranial bleed (current or recent)



other contraindication to heparinization

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ECMO



<b>VV</b> Management

 Adjust FiO2 for PaO2 (oxygenation)

 Adjust Sweep Flow for PCO2 management
(ventilation)

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ECMO



Ventilator Management Goals V-V

(Ventilator)

 FiO2 < 40% and peak pressure <25

 Can use either volume control (2-4cc/kg/IBW) or
pressure control ventilation to achieve goal

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ECMO

 CESAR trial

 Evaluate conventional ventilation vs. ECMO for severe
respiratory failure in adults

 Absence of severe disability at 6 mo

 2001-2006 in England

 180 patients randomly assigned, age 18-65

 Murray score ≥ 3 or pH <7.2

 Excluded if FiO2 >80% for 7 days or high PEEP

 Murray-PaO2/FiO2, #quadrants CXR, PEEP, compliance

 Benefit of ECMO regardless of age, organ failure

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<b>Original Article</b>

<b>Extracorporeal Membrane Oxygenation for Severe </b>
<b>Acute Respiratory Distress Syndrome</b>

Alain Combes, M.D., Ph.D., David Hajage, M.D., Ph.D., Gilles Capellier, M.D., Ph.D.,
Alexandre Demoule, M.D., Ph.D., Sylvain Lavoué, M.D., Christophe Guervilly, M.D.,

Daniel Da Silva, M.D., Lara Zafrani, M.D., Ph.D., Patrice Tirot, M.D., Benoit
Veber, M.D., Ph.D., Eric Maury, M.D., Ph.D., Bruno Levy, M.D., Ph.D., Yves
Cohen, M.D., Ph.D., Christian Richard, M.D., Ph.D., Pierre Kalfon, M.D., Ph.D., Lila

Bouadma, M.D., Ph.D., Hossein Mehdaoui, M.D., Gaëtan Beduneau, M.D., Ph.D.,
Guillaume Lebreton, M.D., Ph.D., Laurent Brochard, M.D., Ph.D., Niall D.

Ferguson, M.D., Eddy Fan, M.D., Ph.D., Arthur S. Slutsky, M.D., Daniel Brodie, M.D.,
Alain Mercat, M.D., Ph.D., for the EOLIA Trial Group, REVA, and ECMONet

N Engl J Med

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<b>Study Overview</b>

• This trial compared extracorporeal membrane oxygenation with
non-ECMO ventilator care in patients with severe ARDS.

• There was no significant between-group difference in 60-day mortality.
• Interpretation was made difficult by crossovers from control to ECMO

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<b>Enrollment, Randomization, and Follow-up of the Trial Participants.</b>

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<b>Kaplan–Meier Survival Estimates in the Intention-to-Treat Population during the First 60 Days </b>

<b>of the Trial.</b>

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<b>End Points.</b>

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So What Are Our REAL

Goals?



Support patient!!!



Limit ventilator induced lung injury (remember all
positive pressure is somewhat harmful)



Mobilize patient to limit impact of critical illness
and hopefully decrease extent of post critical

illness syndrome

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Do You Even Need the Vent?



Mechanical ventilation (MV) is invasive



MV delivers positive pressure which may

compromise the right heart



MV frequently requires some form of sedation
which can be harmful

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Consider Extubation?

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How Did Our Case Patient

Do?



Started on VV ECMO

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Conclusions



VV-ECMO should be part of comprehensive
respiratory failure algorithm

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ECMO

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