how to ventatli e on vv ecmo? and why?€¦ · how to ventatli e on vv ecmo? and why? ibrahim fawzy...
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How to Ventilate on VV ECMO? And Why?
Ibrahim Fawzy Hassan, MDECMO Program Director – Hamad General Hospital
Assistant Professor of Medicine – Weill Cornell Medical College in Qatar
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Disclosure
I have no actual or potential conflict of interest.
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Objectives
• Lung zones in ARDS and VILI• Early vs late course of the lung on ECMO• Ventilation strategies during different courses• Recommendation from various networks• Pplat and TV, PEEP and ∆P • Summary
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Lung Zones in ARDS
Consolidated Lung
Potential for De-recruitment
Normal Lung
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Ventilator Induced Lung Injury
Atelecto-trauma
Bio-trauma
Volum-trauma
Baro-trauma
O2
Toxi
city
Consolidated Lung
Potential for De-recruitment
Normal Lung
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Ventilator Induced Lung Injury
Atelecto-trauma
Bio-trauma
Volum-trauma
Baro-trauma
O2
Toxi
city
Atelectasis
De-recruitment
Over-distention
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Overdistention
“Safe”Window
Derecruitmentand Atelectasis
Bio-trauma
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Injurious Ventilation leads to MODS
Brain Swelling and Ischemia ↑peak pressure,
VILI
↑Gut ischemia and impending necrosis
Anuric acute renal failureCardiovascular instability
Worsening of the acidosis
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Atelecto-trauma
Bio-trauma
Volum-trauma
Baro-trauma
O2
Toxi
city
Atelectasis
De-recruitment
Over-distention
Safe Ventilator Strategy in ARDS
Optimum PEEP
Low TV
Safe Pplateau
Safe
FiO
2
Enhance recruitment
↓De-recruitment
↓Over-distention
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Very Severe ARDSH1N1 PNA FiO2 :100% PEEP : 20 Pplat : 45TV : 5 mL/kg
ABG pH : 6.9 PaO2 : 42 PaCO2 :120 SaO2 : 70%
PEEP : 10 PEEP : 40
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H1N1 PNA FiO2 :100% PEEP : 20 Pplat : 45TV : 5 mL/kg RR : 35
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ABG pH : 6.9 PaO2 : 42 PaCO2 :120 SaO2 : 70%
Very Severe ARDS on ECMOABG pH : 7.35 PaO2 : 70 PaCO2 : 40 SaO2 : 98%
FiO2 :100% PEEP : 20 Pplat : 45TV : 5 mL/kg RR : 35
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What are the Ventilation Options?
FiO2 :100% PEEP : 20 Pplat : 45TV : 5 mL/kg RR : 35
FiO2?
PEEP?
Pplat?
TV?
RR?
Continue the same ventilation?
Protective lung ventilation?
Ultra-protective lung ventilation?
Extubation?
ABG pH : 7.35 PaO2 : 70 PaCO2 : 40 SaO2 : 98%
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ECMO Course
Late Course(Lung Recovery)
Early Course(Inflamed Lung)
First few days to week Severe lung inflammation Uncontrolled source Systemic inflammation Encephalpathy
Second week Lung recovery Source eradicated Less systemic inflammation Weaning
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Optimize ECMO flow and
O2 delivery
Early Diagnosis and aggressive
treatment of the cause
Decrease the risk of VILI
Optimize Native Lung
Function
Early Course(Inflamed Lung)
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What are the Ventilation Options?
FiO2 :100% PEEP : 20 Pplat : 45TV : 5 mL/kg RR : 35
FiO2?
PEEP?
Pplat?
TV?
RR?
Continue the same ventilation?
Protective lung ventilation?
Ultra-protective lung ventilation?
Extubation?
v
v
ABG pH : 7.35 PaO2 : 70 PaCO2 : 40 SaO2 : 98%
vv
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FiO2 :100% PEEP : 20 Pplat : 45TV : 5 mL/kg RR : 35
PEEP?
Pplat?
TV?
What are the Ventilation Options?
Protective lung ventilation?
Ultra-protective lung ventilation? PEEP : High Pplat : < 30TV : 4-6 mL/kg
PEEP : High Pplat : < 20TV : 1-3 mL/kg
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Recommendation and Data
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The use of VV ECMO for ARDS
• RR :3-5 breaths per minute• Peak inspiratory pressures 35 - 45 cmH2O• PEEP:15 and 25 cmH2O
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ELSO
• Managing MV “at low settings to allow lung rest”.
• “A common mistake is to try to recruit lung volume during the acute inflammatory stage early in ECMO.”
• “PEEP: any level, usually 5-15 cmH2O”.
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Cesar Trial
• PCV, peak inspiratory pressure < 20 cmH2O • PEEP of 10 cmH2O• Respiratory rate of 10 breaths/minute• FiO2 30%
Conventional Ventilation orECMO forSevereAdultRespiratory Failure
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Italian ECMO Network
• TV : 3 - 6.3 mL/kg (PBW), median 4.6mL • PEEP : 16 cmH2O, median value• RR : 10 (8-12) breaths/min
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Pplat and TV?
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Study
VT (ml/kg) Mean Pplat (cm H2O) Mortality (%)
Low High Low High Low High
Amato (n =53) 6 12 31.8 34.4 38 71
ARDSnet (n = 861) 6.2 11.8 25 33 31 40
Stewart (n = 120) 7.2 10.8 22.3 26.8 50 47
Brower (n = 52) 7.1 10.3 24.9 30.6 50 46
Brochard (n = 116) 7.1 10.3 25.7 31.7 47 38
Summary of randomized controlled trials of Volume- and Pressure- Limited mechanical ventilation
< 32 >32
< 32
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Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Hager DN, Am J Respir Crit Care Med. 2005 Nov 15
0 20 40 60 80
Mor
talit
y P
ropo
rtio
n
1
2
3
4
5
6
7
8
9
10
Day 1 Plateau Pressure (cm H2O)
The available data from each of these assessments do not support the commonly held view that inspiratoryplateau pressures of 30 to 35 cm H2O are safe.
We could not identify a safe upper limit for plateau pressures in patients with ALI/ARDS.
Retrospective evaluation of the ARDSnet database suggested that VT reduction would have improved outcome, even in patients who already had pPlat < 30 cm H2O.
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Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal. Terragni PP,, Anesthesiology. 2009.
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“ARDSNet” strategy: 25<Pplat<28Entry (N=22)After 72 hrs (N=15)
“ARDSNet” strategy: 28<Pplat<30Entry (N=10)After 72 hrs of LOWER “ARDSNet”/CO2 Removal
(N=10)
Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal. Terragni PP,, Anesthesiology. 2009.
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P < 0.01P = 0.03P < 0.01
Pplat on the 1st day on ECMO Pplat on ECMO - Pplat before ECMO Driving pressure 1st day on ECMO
25 +/- 3
29 +/- 5
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Use High PEEP Level?
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Ventilation Strategy Using Low Tidal Volumes, Recruitment Maneuvers, and High Positive End-Expiratory Pressure for Acute Lung Injury and Acute Respiratory Distress Syndrome, A Randomized Controlled Trial, Maureen O. Meade
Positive End-Expiratory Pressure Setting in Adults With Acute Lung Injury and Acute Respiratory Distress Syndrome, A Randomized Controlled Trial, Alain Mercat
Higher vs Lower Positive End-Expiratory Pressure in Patients With Acute Lung Injury and Acute Respiratory Distress SyndromeSystematic Review and Meta-analysis, Matthias Briel, MD
2010
2004
2008
2008
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Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Schmidt MI, 2015
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Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Schmidt MI, 2015
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Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Schmidt MI, 2015
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Driving Pressure, ∆P?
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2015
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We found that ΔP was the ventilation variable that best stratified risk.
Lower survival rate was observed among patients with higher ΔP and higher survival was observed among patients with lower ΔP, independent of concomitant
variations in PEEP and plateau pressure.
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What do we do in our center?
1. Pplat not to exceed 25 cm.H2O2. PEEP range between 5-15 cm. H2O
– CT guided and P-V loop guided lung recruitment/derecruitment assessment
• LDR : low risk for derecruitment• IDR : Intermediate for risk derecruitment• HDR : High risk for derecruitment
3. Focus on ∆P range not to exceed 10 cm.H2O
4. TV usually 0-3mL/kg of PBW– When TV start to improve we re-assess
weaning potential and focus on lung recruitment and prevention of VIDD
5
10
15
20
25
30
PE
EP PE
EP P
EE
P∆P
∆P
∆P
LDR IDR HDR
Lung
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↓ECMO Support
Management of Recovering
Lung
Mobility and Physiotherapy
Delirium Management
Late Course(Lung Recovery)
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Management of Recovering Lung
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Signs of Lung Recovery on ECMO
Clinical Exam
Native lung O2 transfer
Radiology
Mechanical lung Properties
Dead space fraction
Lung expansion
100% O2 test
More aerated lung
↑TV and ↑Compliance
Decrease in DS fraction
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Ventilation Goals of Recovering Lung on ECMO
To recruit the lung and improve V/Q matching
Avoid Ventilator Induced Diaphragmatic Dysfunction (VIDD)
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Ventilation Goals of Recovering Lung on ECMO
Avoid Ventilator Induced Diaphragmatic Dysfunction (VIDD)
To recruit the lung and improve V/Q matching
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Mechanical Ventilation Options During Recovery Phase
APRV NAVA
PSV PAV
Intellivent
Early Extubation?
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Hemodynamic stability without MSOF Awake enough to protect the airways Secretion is manageable without artificial airways Reasonable gas exchange with minimum ventilator support
FiO2 < 40% PEEP < 5 MV < 10
Extubation on VV ECMO
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Summary
• One size doesn‘t fit all, individual approach is warranted?
• Major area for ongoing research• pPlat < 25 cm . H2O• Individual PEEP titration (CT guided, PV loop,
FRC, etc)?• Should we have more focus on the ∆P?• Spontaneous breathing and early extubation?