High flow VV ECMO vs

ECCO2R in severe ARDS

2019, Toronto

Luciano Gattinoni, MD, FRCP

Georg-August-Universität Göttingen

Germany

Emeritus, Università di Milano

OXYGENATIONFiO2 =1.0 250 mL min-1

CO2 REMOVALVA 9500 mL min-1

VO2

250mL min-1

VCO2

200mL min-1

Sata 98%

PaO2 110 mmHg

CO2 cont 34 mL

PaCO2 15 mmHg

Hb 15 gSatv 82%PvO2 47 mmHgCO2 cont 52 mLPvCO2 43 mmHg

7000 mL min-1

PBF

1100 mL min-1

PBF

Gattinoni et al., European Advances in Intensive Care, 1983; 21: 97-117

CaO2 = CcO2 x (1- Qs/Qtlung x Qs/QtECMO)+CvO2 x (Qs/Qtlung x Qs/QtECMO)

Body Tissues

Natural Lung

O2 natural lung

VO2

Artificial Lung

O2 ECMO

Qs/Qt lungQs/Qt ECMO

CaO2CvO2

ECMO trials

Trial nMortality(control)

Mortality(intervention)

p

Zapol (1979) 90 90% 92% 0.8

Morris (1994) 40 58% 67% 0.8

Peek (2009) 180 46% 37% 0.07

Combes (2018) 249 46% 35% 0.09

Mortality in ECMO trials

0

10

20

30

40

50

60

70

80

90

100

intervention

control

years

mortality

ECMO does not kill !!!

OXYGENATION

NIH ADULT ECMO TRIAL:ZAPOL et al.1979, JAMA • PaO2 < 50 mmHg (2 hours) FiO2

1and PEEP 5 (fast entry)

• PaO2 < 50 (12 hour) FiO2 0.6 and PEEP 5 or a Qs/Qt>30 FiO2 1 and 5 PEEP

PCIRV vs ECCO2R :MORRIS et al. 1994, Am J Respir Crit Care Med

CESAR trialPeek et al. 2009,Lancet

Murray score > 2.5

EOLIA trial

Combes et al. 2018, NEJM

• P/F<50 for at least 3 hours

• P/F<80 for at least 6 hours

• Arterial pH<7.25 with aPCO2> 60 mmHg for at least 6 hours

EOLIA trial, NEJM, 2018

Spinelli et al, ASAIO, 2019

Shunt

HighVA/Q

LowVA/Q

Gas exchange = VA/Q ratio

Vasoconstriction Endothelial Swelling

or Obstruction

+Vasoconstriction

SwellingVasoconstriction

Endothelial Swellingor Obstruction

+

Collapse

Vasoconstriction Endothelial Swelling

or Obstruction Collapse

+

+Obstruction

Anatomical shunt compartment

0.0 0.2 0.4 0.6 0.8 1.0

0

100

200

300

400

PaO

2/F

IO2

(mm

Hg

)

Cressoni M. et al. Crit Care Med. 2008 Mar;36(3):669-75.

Hypoxic vasoconstriction

30

50

70

90

110

130

0,4

0,5

0,6

0,7

10.5

2

10.5

0

2

4

6

8

10

12

30

50

70

90

110

130

Shunt

VE

(L/m

in)

PaO2 (mmHg) PaCO2 (mmHg)

0 1 2 3 ECBF (L/min)

VO2 200 ml/min

VCO2 tot 200 ml/min

FiO2 NL 0,6

FiO2 ML 1

CO 6 L/min

Vd/Vt 0,6

Qs/QT 0,4

0 150 180 190

VCO2 ML

ECMO helper Hypoxic vasoconstriction and shunt

0 1 2 3

VE (L/min)

Rescue VILI

prevention

=

Maintain life

(lowest price

until…)

Clinical indications

Oxygenation

(ARDS)

Hyperinflation

(Asthma, COPD)

EOLIA trial, NEJM, 2018

Rescue?

VILI?

Pre-ECMO

baselineUsual ECMO

ELSO

recommendation

Physiology-based

limits

Vt/IBW

(mL/kg) 6 4 3.5apneic oxygenation

+ 3.6 (sighs)

PEEP

(cmH2O) 13.5 12.0 15.0 22.0Driving pressure

(cmH2O) 17.0 13.5 10.0 10.0Plateau pressure

(cmH2O) 30.5 25.5 25.0 32.0RR

(bpm) 22 16 5 2Mechanical power

(J/min)* 22.7 8.4 2.4 1.3

0

2

4

6

8

10

12

14

0 50 100 150 200 250

VE

(L/m

in)

ECCO2R tot (mL/min)

100

200

300

400

n = 8 pigs

Blood flow(mL/min)

R2 = 0,5

Minimally invasiveECCO2R

Duscio et al. CCM, 2018

Minimally invasiveECCO2R

0

10

20

30

40

50

60

70

80

90

100

0 100 200 300 400 500 600

ECC

O2R

(%

)

100200300400

n = 8 pigs

Duscio et al. CCM, 2018

Blood flow(mL/min)

R2 = 0,6

VCO2 tot (mL/min)

Real question

The best for healing:

• Complete rest with total lung collapse?

• Whatever in between

• Complete rest with total lung inflation?

Near-apneic ventilation decreases lung injury and fibroproliferation in an ARDS model with ECMO

Near-apneicVentilation

PEEP 10Vt 6 mL/KgRR 5DP 10Power 0.4-0.5 J/min

Distant organ failure(Kidney, Liver)

J Araos et al AJRCCM 2019

PEEP 5Vt 10 mL/KgRR 20DP 21-24Power 11-13 J/min

Non-ProtectiveVentilation

ConventionalProtective

PEEP 10Vt 6 mL/KgRR 20DP 14-15Power 7-8 J/min

Courtesy of Dr. Camporota

Histology Score Myofibroblasts Collagen

Near-apnoeic ventilation decreases lung injury and fibroproliferation in an ARDS model with ECMO

J Araos et al AJRCCM 2019Courtesy of Dr. Camporota

lung Rest Or reduced Mechanical ventilation in ECMO

- ROMEO Trial -

ECMO patients

MovementLung rest

OUTCOME time on bypass [∆ 20%]

POPULATION

TREATMENT

Mechanical ventilation to accelerate recovery of lung function in veno-venous extracorporeal support: lung

Rest Or Moderate MEchanical ventilation in ECMO.The ROMEO trial