Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano Disclosure: none Management of native lung on ECMO

The Oxygenator in Venovenous ECMO. Brodie D, Bacchetta M. N Engl J Med 2011;365:

OXYGENATION FiO 2 = mL min -1 VO mL min -1 Sat a 98% P a O mmHg Hb 15 g Sat v 82% 7000 mL min -1 PBF CO 2 REMOVAL VA 2-4 L min -1 VCO mL min -1 CO 2 cont 34 mL P a CO 2 15 mmHg P v O 2 47 mmHg CO 2 cont 52 mL P v CO 2 43 mmHg 1100 mL min -1 PBF Gattinoni et al., European Advances in Intensive Care, 1983; 21:

Arterial Oxygen Saturation (%) Steady state 100 ECMO mathematical model ECMO Blood Flow (%CO) Shunt 40% 85 Shunt 50% 80 Shunt 60% 75

VE (mL*min ) PaCO (mmHg) (mmHg) PaCO2 VE gas flow 10 l/min EC onset Time (h)

BEWARE pH PCO2 !! – RR (always) – TV (almost always) – I/E ( watch out) Guided by: – EndTidalCO2 – ABG in 10’

FR = 30 Paw = [(30*1) + (15*1)] / 2 = Mean airways pressure FR = 15 Paw = [(30*1) + (15*2)] / 3 = ” 15 1”2” 15

BE HAPPY Pplat < 30 TV < 6 ml/Kg or even lower Rate: under debate: 3-10 bpm NO GOODBETTER

Ventillatory strategies in ECMO RecruiterNon Recruiter

lung rest settings were : - peak inspiratory pressure 20–25, - positive endexpiratory pressure 10–15, - rate 10, - FiO2 0 ・ 3.

Minute ventilation was then reduced by adjusting frequency and inspiratory pressure. PEEP was increased to ventilate the patient with the least possible mechanical stress while maintaining a sufficient level of oxygenation (oxygen saturation by pulse oximetry [SpO2] ≥90%).

Ventilator settings were reduced to rest settings as soon as possible after transport to Stockholm and when stable on by-pass. Peak inspiratory pressures were adjusted to cm H20, PEEP5-10 cm H20 and FiO2 0.4.

Non Recruiter strategy In 33 patients (49%), a second access cannula was needed to augment ECMO support.

Non Recruiter strategy Low PEEP (5-10) LPS – PSV High Blood Flow – II° drainage cannula NO PNX Pulmonary Hypertension – V-A bypass? B.F.

Recruiter strategy RMs PEEP Titration SIGH PNX ?

% Opening and closing pressures 50 Opening pressure Closing pressure Paw > 35 cmH 2 O to fully recruit Paw [cmH 2 O] Crotti et al. Am J Respir Crit Care Med 2001

Modern PEEP Titration

Sigh ( 1 ogni 3 min ) Effects of periodic lung recruitment maneuvers on gas exchange and respiratory mechanics in mechanically ventilated ARDS patients. G. Foti, M.Cereda, M.E. Sparacino, L. De Marchi,F. Villa, A. Pesenti Intensive Care Med (2000) 26: Pressione di reclutamento ↑ Oxygenation ↓ Qva/Qt SIGH

Always keeping in mind that Packer et al Crit Care Med 1993;31:

FRC V E (L/min) RATIO NORMAL ARDS SPECIFIC HYPERVENTILATION

Hager DN AmJ Respir Crit Care Med :2005: 172: 1241

Normal sheeps randomly assigned to 3 groups: A: control MV 48 hrs B: PIP 50 cm H 2 O RR 1-3 bpm C: PIP 50 cm H 2 O RR 12 bpm CO Kolobow T, Moretti MP, Fumagalli R et al Am Rev Resp Dis 1987, 135:

Group AGroup BGroup C Normal5-- Light damage 1-- Moderate211 Severe-1- Very severe-58 Kolobow T, Moretti MP, Fumagalli R et al Am Rev Resp Dis 1987, 135:

Spontaneous breathing in ARDS spontaneous breathingcontrolled ventilation, NMBA

Control of breathing using an extracorporeal membrane lung The lung rest concept Kolobow T, Gattinoni et al., Anesthesiology, 1977; 46:

The most appropriate ventilator settings for patients with severe ARDS who are undergoing ECMO are unknown.

Whenever possible, we aim for limitation of pressure and set respiratory rates that are at least as restrictive as those described above, along with tidal volumes that are typically main- tained below 4 ml per kilogram of predicted body weight, to minimize the potential for ventilator- associated lung injury. Whatever the approach, applying adequate PEEP is important to maintain airway patency at the low lung volumes attained with these settings.

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