How to Ventilate on VV ECMO? And Why?

Ibrahim Fawzy Hassan, MDECMO Program Director – Hamad General Hospital

Assistant Professor of Medicine – Weill Cornell Medical College in Qatar

Disclosure

I have no actual or potential conflict of interest.

Objectives

• Lung zones in ARDS and VILI• Early vs late course of the lung on ECMO• Ventilation strategies during different courses• Recommendation from various networks• Pplat and TV, PEEP and ∆P • Summary

Lung Zones in ARDS

Consolidated Lung

Potential for De-recruitment

Normal Lung

Ventilator Induced Lung Injury

Atelecto-trauma

Bio-trauma

Volum-trauma

Baro-trauma

O2

Toxi

city

Consolidated Lung

Potential for De-recruitment

Normal Lung

Ventilator Induced Lung Injury

Atelecto-trauma

Bio-trauma

Volum-trauma

Baro-trauma

O2

Toxi

city

Atelectasis

De-recruitment

Over-distention

Overdistention

“Safe”Window

Derecruitmentand Atelectasis

Bio-trauma

Injurious Ventilation leads to MODS

Brain Swelling and Ischemia ↑peak pressure,

VILI

↑Gut ischemia and impending necrosis

Anuric acute renal failureCardiovascular instability

Worsening of the acidosis

Atelecto-trauma

Bio-trauma

Volum-trauma

Baro-trauma

O2

Toxi

city

Atelectasis

De-recruitment

Over-distention

Safe Ventilator Strategy in ARDS

Optimum PEEP

Low TV

Safe Pplateau

Safe

FiO

2

Enhance recruitment

↓De-recruitment

↓Over-distention

Very Severe ARDSH1N1 PNA FiO2 :100% PEEP : 20 Pplat : 45TV : 5 mL/kg

ABG pH : 6.9 PaO2 : 42 PaCO2 :120 SaO2 : 70%

PEEP : 10 PEEP : 40

H1N1 PNA FiO2 :100% PEEP : 20 Pplat : 45TV : 5 mL/kg RR : 35

ABG pH : 6.9 PaO2 : 42 PaCO2 :120 SaO2 : 70%

Very Severe ARDS on ECMOABG pH : 7.35 PaO2 : 70 PaCO2 : 40 SaO2 : 98%

FiO2 :100% PEEP : 20 Pplat : 45TV : 5 mL/kg RR : 35

What are the Ventilation Options?

FiO2 :100% PEEP : 20 Pplat : 45TV : 5 mL/kg RR : 35

FiO2?

PEEP?

Pplat?

TV?

RR?

Continue the same ventilation?

Protective lung ventilation?

Ultra-protective lung ventilation?

Extubation?

ABG pH : 7.35 PaO2 : 70 PaCO2 : 40 SaO2 : 98%

ECMO Course

Late Course(Lung Recovery)

Early Course(Inflamed Lung)

First few days to week Severe lung inflammation Uncontrolled source Systemic inflammation Encephalpathy

Second week Lung recovery Source eradicated Less systemic inflammation Weaning

Optimize ECMO flow and

O2 delivery

Early Diagnosis and aggressive

treatment of the cause

Decrease the risk of VILI

Optimize Native Lung

Function

Early Course(Inflamed Lung)

What are the Ventilation Options?

FiO2 :100% PEEP : 20 Pplat : 45TV : 5 mL/kg RR : 35

FiO2?

PEEP?

Pplat?

TV?

RR?

Continue the same ventilation?

Protective lung ventilation?

Ultra-protective lung ventilation?

Extubation?

v

v

ABG pH : 7.35 PaO2 : 70 PaCO2 : 40 SaO2 : 98%

vv

FiO2 :100% PEEP : 20 Pplat : 45TV : 5 mL/kg RR : 35

PEEP?

Pplat?

TV?

What are the Ventilation Options?

Protective lung ventilation?

Ultra-protective lung ventilation? PEEP : High Pplat : < 30TV : 4-6 mL/kg

PEEP : High Pplat : < 20TV : 1-3 mL/kg

Recommendation and Data

The use of VV ECMO for ARDS

• RR :3-5 breaths per minute• Peak inspiratory pressures 35 - 45 cmH2O• PEEP:15 and 25 cmH2O

ELSO

• Managing MV “at low settings to allow lung rest”.

• “A common mistake is to try to recruit lung volume during the acute inflammatory stage early in ECMO.”

• “PEEP: any level, usually 5-15 cmH2O”.

Cesar Trial

• PCV, peak inspiratory pressure < 20 cmH2O • PEEP of 10 cmH2O• Respiratory rate of 10 breaths/minute• FiO2 30%

Conventional Ventilation orECMO forSevereAdultRespiratory Failure

Italian ECMO Network

• TV : 3 - 6.3 mL/kg (PBW), median 4.6mL • PEEP : 16 cmH2O, median value• RR : 10 (8-12) breaths/min

Pplat and TV?

Study

VT (ml/kg) Mean Pplat (cm H2O) Mortality (%)

Low High Low High Low High

Amato (n =53) 6 12 31.8 34.4 38 71

ARDSnet (n = 861) 6.2 11.8 25 33 31 40

Stewart (n = 120) 7.2 10.8 22.3 26.8 50 47

Brower (n = 52) 7.1 10.3 24.9 30.6 50 46

Brochard (n = 116) 7.1 10.3 25.7 31.7 47 38

Summary of randomized controlled trials of Volume- and Pressure- Limited mechanical ventilation

< 32 >32

< 32

Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Hager DN, Am J Respir Crit Care Med. 2005 Nov 15

0 20 40 60 80

Mor

talit

y P

ropo

rtio

n

1

2

3

4

5

6

7

8

9

10

Day 1 Plateau Pressure (cm H2O)

The available data from each of these assessments do not support the commonly held view that inspiratoryplateau pressures of 30 to 35 cm H2O are safe.

We could not identify a safe upper limit for plateau pressures in patients with ALI/ARDS.

Retrospective evaluation of the ARDSnet database suggested that VT reduction would have improved outcome, even in patients who already had pPlat < 30 cm H2O.

Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal. Terragni PP,, Anesthesiology. 2009.

“ARDSNet” strategy: 25<Pplat<28Entry (N=22)After 72 hrs (N=15)

“ARDSNet” strategy: 28<Pplat<30Entry (N=10)After 72 hrs of LOWER “ARDSNet”/CO2 Removal

(N=10)

Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal. Terragni PP,, Anesthesiology. 2009.

P < 0.01P = 0.03P < 0.01

Pplat on the 1st day on ECMO Pplat on ECMO - Pplat before ECMO Driving pressure 1st day on ECMO

25 +/- 3

29 +/- 5

Use High PEEP Level?

Ventilation Strategy Using Low Tidal Volumes, Recruitment Maneuvers, and High Positive End-Expiratory Pressure for Acute Lung Injury and Acute Respiratory Distress Syndrome, A Randomized Controlled Trial, Maureen O. Meade

Positive End-Expiratory Pressure Setting in Adults With Acute Lung Injury and Acute Respiratory Distress Syndrome, A Randomized Controlled Trial, Alain Mercat

Higher vs Lower Positive End-Expiratory Pressure in Patients With Acute Lung Injury and Acute Respiratory Distress SyndromeSystematic Review and Meta-analysis, Matthias Briel, MD

2010

2004

2008

2008

Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Schmidt MI, 2015

Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Schmidt MI, 2015

Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Schmidt MI, 2015

Driving Pressure, ∆P?

2015

We found that ΔP was the ventilation variable that best stratified risk.

Lower survival rate was observed among patients with higher ΔP and higher survival was observed among patients with lower ΔP, independent of concomitant

variations in PEEP and plateau pressure.

What do we do in our center?

1. Pplat not to exceed 25 cm.H2O2. PEEP range between 5-15 cm. H2O

– CT guided and P-V loop guided lung recruitment/derecruitment assessment

• LDR : low risk for derecruitment• IDR : Intermediate for risk derecruitment• HDR : High risk for derecruitment

3. Focus on ∆P range not to exceed 10 cm.H2O

4. TV usually 0-3mL/kg of PBW– When TV start to improve we re-assess

weaning potential and focus on lung recruitment and prevention of VIDD

5

10

15

20

25

30

PE

EP PE

EP P

EE

P∆P

∆P

∆P

LDR IDR HDR

Lung

↓ECMO Support

Management of Recovering

Lung

Mobility and Physiotherapy

Delirium Management

Late Course(Lung Recovery)

Management of Recovering Lung

Signs of Lung Recovery on ECMO

Clinical Exam

Native lung O2 transfer

Radiology

Mechanical lung Properties

Dead space fraction

Lung expansion

100% O2 test

More aerated lung

↑TV and ↑Compliance

Decrease in DS fraction

Ventilation Goals of Recovering Lung on ECMO

To recruit the lung and improve V/Q matching

Avoid Ventilator Induced Diaphragmatic Dysfunction (VIDD)

Ventilation Goals of Recovering Lung on ECMO

Avoid Ventilator Induced Diaphragmatic Dysfunction (VIDD)

To recruit the lung and improve V/Q matching

Mechanical Ventilation Options During Recovery Phase

APRV NAVA

PSV PAV

Intellivent

Early Extubation?

Hemodynamic stability without MSOF Awake enough to protect the airways Secretion is manageable without artificial airways Reasonable gas exchange with minimum ventilator support

FiO2 < 40% PEEP < 5 MV < 10

Extubation on VV ECMO

Summary

• One size doesn‘t fit all, individual approach is warranted?

• Major area for ongoing research• pPlat < 25 cm . H2O• Individual PEEP titration (CT guided, PV loop,

FRC, etc)?• Should we have more focus on the ∆P?• Spontaneous breathing and early extubation?

Thank you