1. Extracorporeal CO2 Removal in ARDS
Antonio Pesenti
University of Milano Bicocca
Italy

2. HISTORY First RCT on ECMO in ARDS.
No MV protocol during ECMO, only a generic indication of reducing inspiratory pressure and FiO2

3. Adult respiratory distress syndrome (ARDS): why did ECMO fail
Adult respiratory distress syndrome (ARDS): why did ECMO fail? Kolobow T, et al Int J Artif Organs ;4:58
We believe severely diseased lungs have a chance to heal only if the environment remains conducive to the healing of the lung.
This environment does not consist of high airway pressures, high tidal volumes, high PEEP, high FiO2……..

4. Artificial Lung From Oxygenators: Buying time with artificial lungs To
Zapol WM, Kits RJ, NEJM 1972; 286 (12) To
Artificial lungs:
Resting the lung
Gattinoni L 1976? Personal Communication

5. NEJM 2000; 342:1301

7. SPECIFIC HYPERVENTILATION
VE (L/min)
FRC
RATIO
NORMAL
2500
< 7
< 2.8
ARDS
1000
> 15
> 15

9. 100 X 100 VA (actual) VA (control) 50 50 100 VCO2 (CDML) VCO2 (Total)
MECH. VENTILATION
THEORETICAL
SPONT. VENTILATION
VA (actual)
VA (control)
X 100 50 50
100
VCO2 (CDML)
VCO2 (Total)
X 100

10. Extracorporeal CO2 removal
Reducing ventilation anywhere down to 0 according to the proportion of VCO2 removed
No ventilation , no VILI

11. OXYGENATION FiO2 =1.0 250 mL min-1 VO2 7000 mL min-1 250 PBF mL min-1
Sata 98%
VO2
250
mL min-1
PaO2 110 mmHg
Hb 15 g
Satv 82%
PvO2 47 mmHg
CO2 cont 52 mL
PvCO2 43 mmHg
CO2 REMOVAL
VA 9500 mL min-1
VCO2
200
mL min-1
1100 mL min-1
PBF
CO2 cont 34 mL
PaCO2 15 mmHg
Gattinoni et al., International Anesthesiology Clinics, 1983; 21:

12. The technique seems to prevent the pulmonary barotrauma and extrapulmonary derangements caused by conventional mechanical ventilation 12

13. ECMO CRITERIA + TSLC < 30 cmH2O 43 patients 21 survivors (49%)
LFPPV ECCO2R IN SEVERE ACUTE RESPIRATORY FAILURE GATTINONI et al: JAMA 1986
ECMO CRITERIA + TSLC < 30 cmH2O
43 patients survivors (49%)
Mean by-pass length:
Survivors ± 3.5 days
NonSurvivors ± 6.6 days
Bleeding: 1800 ± 500 ml/day

14. 14

15. 15

16. Pumpless extracorporeal lung assist and adult respiratory distress syndrome Reng M et al., The Lancet 2000; 356 (15)

17. PaCO2 VE FROM TO 8 patients 72 hr AVCO2R 90.8 ± 7.5 6.92 ± 1.6
Total extracorporeal arteriovenous carbon dioxide removal in ARF: a phase I clinical study
Conrad S et al. ICM 2001; 27: 1340
8 patients
72 hr AVCO2R
PaCO2 VE
FROM
90.8 ± 7.5
6.92 ± 1.6 TO
51.8 ± 3.1
3.0 ± 0.53

18. Critical Care 2006, 10:R151 18

20. Anesthesiology. 2009 ;111: 826 PaCO2 (mmHg) Arterial pH * * * * * * *
baseline T0 T24 T48 T baseline T0 T24 T48 T72
Anesthesiology ;111: 826 20

21. Arteriovenous extracorporeal respiratory support
Implementation

22. Vv ILA with a pump

23. The A Lung

24. PALP System

26. Extracorporeal CO2 Removal Physiological Side Effects
Decreased PA O2: ( Due to decreased QR)
Decreased TV - Decrecruitment
Higher PEEP equal Paw
Ineffective Coughing ( ?)

27. Marcolin R et al Trans Am Soc Artif Intern Organs 1986

28. Marcolin R et al Trans Am Soc Artif Intern Organs 1986

29. Trans Am Soc Artif Intern Organs 1986
Marcolin R et al:
Trans Am Soc Artif Intern Organs 1986

31. What influences the respiratory drive in COPD pts undergoing PECOR?
GF 10 L/min, VCO2ML 134 mL/min
GF 5 L/min, VCO2ML 108 mL/min
GF 2.5 L/min, VCO2ML 83 mL/min
GF 0 L/min, VCO2ML 0 mL/min 4 3 2 1

32. What influences the respiratory drive in COPD pts undergoing PECOR?4 3 2 1
GF 10 L/min, VCO2ML 134 mL/min
GF 5 L/min, VCO2ML 108 mL/min
GF 2.5 L/min, VCO2ML 83 mL/min
GF 0 L/min, VCO2ML 0 mL/min
R² = 0.96

33. Gas Flow Membrane Lung (l/min)
100 80 60 40 20
VCO2 Natural Lung %
VCO2 Membrane Lung % 6 4 2
0,4
Gas Flow Membrane Lung (l/min) 33

34. What influences the respiratory drive in ARDS pts undergoing ECMO?

35. Extracorporeal CO2 Removal Physiological Side Effects
Decreased PA O2: ( Due to decreased QR)
Decreased TV - Decrecruitment
Higher PEEP Maintain Paw
Ineffective Coughing ( ?)

36. PAO2= FiO2 *713 - ( PaCO2/R) FiO2 1 PACO2 = 35 mmHg PAO2 300 mmHg 0.5
AIR
PAO2 100 mmHg
0.5 1 R

37. Cereda M et al. Chest 1996; 109: 480

38. FUTURE VILI PREVENTION: THE IDEAL TOOL
Peripheral low flow cannulation
ml/ min blood flow
50-80 % total CO2 production
Regional anticoagulation
Simple Safe circuitry ( CVVH) 38

39. Zanella A et al

40. Total CO2 elimination by a membrane lung
200
Δ 69%
180
160
Δ 27%
140
Δ18%
120
VCO2 (ml/min)
100 80 60
VCO2 standard conditions 40
VCO ALCOR 20 1 2 3 4 5 6
Acid infusion (mmol/min) 40

41. ECLA: different techniques for different goals
Rescue of most severe hypoxemia
ARDS
Hyper protective ventilation
Alternative to invasive ventilation
ARDS, COPD

42. Extracorporeal lung Assist 3 ALTERNATIVE TO VENTILATION
BLOOD FLOW UNDEFINED
SOUND PATHOPHYSIOLOGY

43. The three evils of MECHANICAL VENTILATION
VILI
VAP
SEDATION

44. Extracorporeal support rationale
“... the best therapeutic strategy, to reduce the risk of new pneumothoraces and to stop the air leak, would be to dispense with mechanical ventilation or any form of positive airway pressure. Spontaneous breathing could be maintained by supplementing the spontaneous CO2 clearance with partial extracorporeal CO2 removal.”
Pesenti A., et al: Percutaneous Extracorporeal CO2 Removal in a Patient with Bullous Emphysema with Recurrent Bilateral Pneumothoraces and Respiratory Failure. Anesthesiology 1990; 72: