Ventilator ECMO Interactions

Lorenzo Del Sorbo, MD

CCCF

Toronto, October 2nd 2017

Disclosure

• Relevant relationships with commercial entities: none

• Potential for conflicts within this presentation: none

Oxygenation

CO2 clearance

Survival ?

Del Sorbo et al. Lancet Resp Med. 2014

ICU VENTILATOR

Fan E et al.Am J Respir Crit Care Med. 2017

Brodie D and Bacchetta M, NEJM 2011

Controversial issues in the management of ECMO:-….

-Mechanical ventilation strategies

Adult respiratory ECMO: mortality rate 55%

AJRCCM 2013

Multivariate analysis

age (OR 1.09; 95% CI: 1.04–1.15; P < 0.01)

lactate under ECMO (OR 1.42; 95% CI: 1.18–1.82; P < 0.01)

higher Pplat first day on ECMO (OR 1.33; 95% CI: 1.14–1.59; P < 0.01)

were the only three variables significantly associated with ICU death

Pham et al. Am J Respir Crit Care Med. 2013

Intensive Care Med (2016) 42:1672–1684

Design: Retrospective observational studySetting: Three international high-volume ECMO centersPatients: 168 patients on VV-ECMO for ARDS

Crit Care Med 2015

VENTILATOR ECMO interactions

Diverse ventilatory strategies during VV-ECMO

ELSO GuidelinesVentilator management

The goal of ventilator management on ECLS is to use FiO2 <0.4, and non-damaging “rest settings”

Pressure controlled ventilation at 25-15, I:E 2:1, rate 5, FiO2 50%, FiN2 50%

Positive pressure is continued to maintain some lung inflation, but PPlat over 25 can cause ongoing lung damage

PEEP can be as high as tolerated

VENTILATOR VV-ECMO interactions

Pathophysiological considerations

Del Sorbo et al Minerva Anest. 2014

High susceptibility to VILI(baby lung)

No response to conventional approaches (RM, prone positioning, high PEEP)

VV-ECMO

The role of mechanical ventilation during VV-ECMO: pathophysiological considerations - 1

N Engl J Med 2013;369:2126-36.

Del Sorbo et al Lancet, Resp Med. 2014

The role of mechanical ventilation during VV-ECMO: pathophysiological considerations - 2

MV is not absolutely necessary

during VV-ECMO to facilitate gas exchange

ICU VENTILATOR

Del Sorbo et al Lancet, Resp Med. 2014

The role of mechanical ventilation during VV-ECMO: pathophysiological considerations - 3

During VV-ECMO lung is perfused with

oxygenated blood

ICU VENTILATOR

The role of mechanical ventilation during VV-ECMO: pathophysiological considerations

Del Sorbo et al Minerva Anest. 2014

Mechanical VentilationImproving

Gas Exchange VILI

The role of mechanical ventilation during VV-ECMO: pathophysiological considerations

Del Sorbo et al Minerva Anest. 2014

ImprovingGas Exchange

VILI

VV-ECMO

VENTILATOR ECMO interactions

What tidal volume?

Del Sorbo et al Minerva Anest. 2014

VENTILATOR ECMO interactions

Spontaneous breathing?

Healthy sheep

Sheep with ARDS

ICM. 2016

Cross-over study: PSV vs NAVA8 Pts on VV-ECMO recovering from ARDS

Anesthesiology 2016

Cross-over study: PSV vs NAVA8 Pts on VV-ECMO recovering from ARDS

Anesthesiology 2016

VENTILATOR ECMO interactions

What PEEP?

Del Sorbo et al Minerva Anest. 2014

Suter, NEJM 1975

Del Sorbo et al Minerva Anest. 2014

Madjdpour C. Am J Physiol Lung Cell Mol Physiol, 2003

Hypoxia induced lung inflammation

Veno-venous Extracorporeal Membrane Oxygenation

Del Sorbo et al. Lancet Resp Med. 2014

Bellani G.

Lungs of patients with acute respiratory distress syndrome show

diffuse inflammation in normally aerated regions: A [18F]-fluoro-2-

deoxy-D-glucose PET/CT study

Lobar pneumonia

Extracorporeal gas exchange in ECMO allows us to separate the impact of inspiratory tidal volumes and end-expiratory lung volumes on VILI, which is technically more difficult in patients with severe ARDS who are supported solely with mechanical ventilation

Strategies for Optimal Lung Ventilation in ECMO for ARDS: The SOLVE ARDS study

Primary Hypotheses

1. Reducing tidal stress and strain to zero (by decreasing driving pressure/Tidal volume) will mitigate VILI during VV-ECMO (tested in Phase 1)

1. Reducing tidal strain (by adjusting end-expiratory pressure to maximize compliance) will mitigate VILI during VV-ECMO (tested in Phase 2)

Secondary Objectives

• To evaluate effects of changing driving pressure and end-expiratory pressure on:

– RV function

– Lung ultrasound abnormalities

VENTILATOR ECMO interactions

VV-ECMO as alternative to MV?

ECMO as alternative to MV in ARDS: ?

Hoeper MM et al. ICM. 2013

32-year-old woman with advanced cystic fibrosis lung disease

Conclusions

Ventilator ECMO interactions

-May impact survival-Diverse ventilatory strategies-Different risk/benefit profile of MV (high risk of VILI)-On-going effort to identify the best conditions to facilitate lung protection/healing (i.e. The SOLVE ARDS study)

-VV-ECMO as alternative to MV ??

lorenzo.delsorbo@uhn.ca

Thank you!