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

3. The Oxygenator in Venovenous ECMO. Brodie D, Bacchetta M. N Engl J Med 2011;365:1905-1914

4. OXYGENATION FiO 2 =1.0 250 mL min -1 VO 2 250 mL min -1 Sat a 98% P a O 2 110 mmHg Hb 15 g Sat v 82% 7000 mL min -1 PBF CO 2 REMOVAL VA 2-4 L min -1 VCO 2 200 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: 97-117

5. Arterial Oxygen Saturation (%) Steady state 100 ECMO mathematical model ECMO Blood Flow (%CO) 10203040506070 95 90 Shunt 40% 85 Shunt 50% 80 Shunt 60% 75

6. VE (mL*min ) PaCO (mmHg) (mmHg) 2 1 10 4 PaCO2 VE gas flow 10 l/min EC onset 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 50 49 48 47 46 45 44 43 42 41 061218243036424854606672 Time (h)

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

8. FR = 30 Paw = [(30*1) + (15*1)] / 2 = 22.5 30 Mean airways pressure FR = 15 Paw = [(30*1) + (15*2)] / 3 = 20 30 1” 15 1”2” 15

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

10. Ventillatory strategies in ECMO RecruiterNon Recruiter

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

13. 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%).

14. 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 20-25 cm H20, PEEP5-10 cm H20 and FiO2 0.4.

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

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

17. Recruiter strategy RMs PEEP Titration SIGH PNX ?

18. % Opening and closing pressures 50 Opening pressure Closing pressure Paw > 35 cmH 2 O to fully recruit 05 40 30 20 10 0 10 15 20 25 30 35 40 45 50 Paw [cmH 2 O] Crotti et al. Am J Respir Crit Care Med 2001

19. Modern PEEP Titration 10 12 15 7 10

20. 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: 501-507 Pressione di reclutamento ↑ Oxygenation ↓ Qva/Qt SIGH

21. Always keeping in mind that Packer et al Crit Care Med 1993;31:131-143

22. FRC V E (L/min) RATIO NORMAL ARDS 250072.8 5001224 SPECIFIC HYPERVENTILATION

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

24. 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 2 3.8 Kolobow T, Moretti MP, Fumagalli R et al Am Rev Resp Dis 1987, 135: 312-315

25. 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: 312-315

26. Spontaneous breathing in ARDS spontaneous breathingcontrolled ventilation, NMBA

27. Control of breathing using an extracorporeal membrane lung The lung rest concept Kolobow T, Gattinoni et al., Anesthesiology, 1977; 46: 138-141

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

29. 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.

30. THANKS