ECMO: Thông khí nhân tạo Những vấn đề quan tâm Kenneth Lyn-Kew, MD

 high pressure (peak inspiratory pressure >30 cmH2O) and/or high FiO2 (>0.8) ventilation for more than 7 days (relative contraindication)... ECMO[r]

ECMO:

Mechanical Ventilation

Considerations

Kenneth Lyn-Kew, MD National Jewish Health

Goals

Case

 38yo male presents with day of malaise and SOB  Pt intubated and has progressive respiratory failure  Pt on cc/kg/IBW, PEEP 20, Pplat 34, FIO2 1.0 in

prone position

What you next?

 A) Paralyze him?

VV-ECMO

VV-ECMO

 ELSO Guidelines

 V-V Indications

 Respiratory support-consider if mortality >50% and recommended if mortality >80%

 ARDS/hypoxemic respiratory failure

 PaO2 to FiO2 ratio less than 80, despite salvage therapies for 6+ hrs

 Uncompensated hypercapnia (ph<7.15 despite measures)

 Hypercapneic respiratory failure (severe COPD/asthma exacerbation)

 Lung transplant candidates

 Severe air leak patients

VV-ECMO

 CESAR study inclusion criteria (Lancet 2009; 374: 1351–63)

 Indications:

 age ≥16 years

 potentially reversible severe acute respiratory failure

 no limitation to on-going life-sustaining treatment

 Murray score ≥3.0 (consider referral if ≥2.5 and rapid clinical deterioration) OR

VV ECMO

 V-V Contraindications

 No absolute contraindications but the following are associated with a poor outcome

 Mechanical ventilation with high support (Fio2>90% and/or P-plat >30 for days)

 CNS hemorrhage

 Pharmacologic immunosuppression (ANC<400)

 Non-recoverable comorbidity

VV-ECMO

Contraindications (CESAR):

 intracranial bleed (current or recent)

 other contraindication to heparinization

ECMO

 VV Management

 Adjust FiO2 for PaO2 (oxygenation)

 Adjust Sweep Flow for PCO2 management (ventilation)

ECMO

 Ventilator Management Goals V-V

(Ventilator)

 FiO2 < 40% and peak pressure <25

 Can use either volume control (2-4cc/kg/IBW) or pressure control ventilation to achieve goal

ECMO

 CESAR trial

 Evaluate conventional ventilation vs ECMO for severe respiratory failure in adults

 Absence of severe disability at mo

 2001-2006 in England

 180 patients randomly assigned, age 18-65

 Murray score ≥ or pH <7.2

 Excluded if FiO2 >80% for days or high PEEP

 Murray-PaO2/FiO2, #quadrants CXR, PEEP, compliance

 Benefit of ECMO regardless of age, organ failure

Original Article

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome

Alain Combes, M.D., Ph.D., David Hajage, M.D., Ph.D., Gilles Capellier, M.D., Ph.D., Alexandre Demoule, M.D., Ph.D., Sylvain Lavoué, M.D., Christophe Guervilly, M.D.,

Daniel Da Silva, M.D., Lara Zafrani, M.D., Ph.D., Patrice Tirot, M.D., Benoit Veber, M.D., Ph.D., Eric Maury, M.D., Ph.D., Bruno Levy, M.D., Ph.D., Yves Cohen, M.D., Ph.D., Christian Richard, M.D., Ph.D., Pierre Kalfon, M.D., Ph.D., Lila

Bouadma, M.D., Ph.D., Hossein Mehdaoui, M.D., Gaëtan Beduneau, M.D., Ph.D., Guillaume Lebreton, M.D., Ph.D., Laurent Brochard, M.D., Ph.D., Niall D

Ferguson, M.D., Eddy Fan, M.D., Ph.D., Arthur S Slutsky, M.D., Daniel Brodie, M.D., Alain Mercat, M.D., Ph.D., for the EOLIA Trial Group, REVA, and ECMONet

N Engl J Med

Study Overview

• This trial compared extracorporeal membrane oxygenation with non-ECMO ventilator care in patients with severe ARDS

• There was no significant between-group difference in 60-day mortality • Interpretation was made difficult by crossovers from control to ECMO

Enrollment, Randomization, and Follow-up of the Trial Participants.

Kaplan–Meier Survival Estimates in the Intention-to-Treat Population during the First 60 Days

of the Trial.

End Points.

So What Are Our REAL Goals?

 Support patient!!!

 Limit ventilator induced lung injury (remember all positive pressure is somewhat harmful)

 Mobilize patient to limit impact of critical illness and hopefully decrease extent of post critical

illness syndrome

Do You Even Need the Vent?

 Mechanical ventilation (MV) is invasive  MV delivers positive pressure which may

compromise the right heart

 MV frequently requires some form of sedation which can be harmful

Consider Extubation?

How Did Our Case Patient Do?

 Started on VV ECMO

Conclusions

 VV-ECMO should be part of comprehensive respiratory failure algorithm

ECMO