Pesenti.pdf · NIH ECMO STUDY • FAST ENTRY CRITERIA –PaO2 < 50 mmHg 3 times 1hr interval ( 2...
Transcript of Pesenti.pdf · NIH ECMO STUDY • FAST ENTRY CRITERIA –PaO2 < 50 mmHg 3 times 1hr interval ( 2...
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ECMO : da dove siamo partiti?
Antonio Pesenti MD
University of Milano BicoccaItaly
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A Brilliant Investigator’s Career
• First decade :
– A new method of respiratory extracorporeal support
• Second decade :
– Respiratory Extracorporeal Support : state of the Art
• Third decade :
– Respiratory Extracorporeal Support : History
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Buying time with artificial lungs
Zapol WM, Kits RJ, NEJM 1972; 286 (12)
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NIH ECMO STUDY
• FAST ENTRY CRITERIA
– PaO2 < 50 mmHg 3 times 1hr interval ( 2 hrs)
– Fi O2 1 - PEEP > 5 cmH2O
• SLOW ENTRY CRITERIA
• PaO2 < 50 mmHg 3 times 6hr interval (12 hrs)
• FiO2 0.6 - PEEP > 5 cm H2O
– OR
• Qs/Qt > 30% at FiO2 1
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NIH
• Expected mortality rate was > 65%
• Observed mortality rate was 92%
• Investigators decided to proceed to an additional data collection :
• All ARF patients undergoing positive airway pressure with an FiO2 > .5 for more than 24 hrs
NIH ECMO STUDY
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NIH ECMO Trial
0
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0 2 4 6 8 10 12 14
Days From Entry
Su
rviv
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Pati
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ts MV
ECMO
Zapol WM: JAMA 1979; 242: 2193-6
From Conrad SA slide on internet
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Ted Kolobow MD
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Why Did ECMO Fail?
• Severely diseased lungs have a chance to heal only if the environment remains conducive to the healing of the lungs.
• This environment does not consist of high airway pressures, high tidal volumes, high PEEP, high FiO2…..
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Luciano Gattinoni, MD
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From Oxygenators:Buying time with artificial lungs
Zapol WM, Kits RJ, NEJM 1972; 286 (12)
ToArtificial lungs:Resting the lung
Gattinoni L 1976? Personal Communication
Artificial Lung
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CONTENTION
• We can do without Mechanical Ventilation if we do not need to breath out CO2 trough the lungs
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Kolobow et al Trans. Am. Soc. Artif. Intern. Organs. 1977. 23: 17
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Extracorporeal Gas Exchange
• ECMO
– high blood flow ( 4-6 l/min)
• ECCO2R
– low blood flow ( 0.5 – 2.5 l/min)
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The three evils of MECHANICAL VENTILATION
• VILI
• VAP
• SEDATION
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ARTIFICIAL ORGANS FOR RESPIRATORY FAILURE
Ventilatory
Membrane lung
Parenchimal
Mechanical ventilation
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NEJM 2002:346: 1281
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ARDS Pathophysiology
• ARDS is not just an hypoxic syndrome
• ARDS is a “Hypercapnic” syndrome
– Pulmonary vascular occlusion
– High dead space
– High minute ventilation
– High PAP
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Extracorporeal CO2 removal
• Reducing ventilation anywhere down to 0 according to the
proportion of VCO2 removed
• No ventilation , no VILI
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Early ARDS
• ECCO2R to :
– prevent intubation
– extend NIV application
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J. M. Tonnelier Intensive Care Med 2003: 29: 2077
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Variable No tube To tube P tresh sens spc
PaO2/FiO2
basal111±38 105±33 .06 <102 0.6 0.66
PaO2/FiO2
1 hr195±66 168±48 0.09 <175 0.59 0.65
RR basal
35±5 36±5 0.27 >31 0.9 0.25
RR 1 hr
27±5 30±7 0.006 >29 0.63 0.67
Antonelli : Crit Care Med. 2007 Jan;35(1):18-25.
A multiple-center survey on the use in clinical practice of NIV as a first-line intervention for ARDS.
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ARDS Status
• ECCO2R to :
– from 6 to 3ml/kg and lower
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Hager Am J Resp Crit Care Med 2005
Association between mortalityand Pplat
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The technique seems to prevent the pulmonary barotrauma and
extrapulmonary derangements caused by conventional mechanical
ventilation
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PaCO2 (mmHg) Arterial pH
baseline T0 T24 T48 T72 baseline T0 T24 T48 T72
7.0
7.1
7.2
7.3
7.4
7.5
*
* * *
***
*
30
40
50
60
70
80
90
Anesthesiology. 2009 ;111: 826
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T. Bein et al : Intensive Care Med 2013
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ARDS Recovering
• ECCO2R to allow :
– early spontaneous breathing
– early extubation
– early NIV or CPAP
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ECMO REVISITED
The International Journal of Artificial Organs 10, 1, 1987
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Extracorporeal CO2 RemovalPhysiological Side Effects
• Extracorporeal Carbon Dioxide Removal is an experimental technique
• Extracorporeal Carbon Dioxide Removal effects on outcome are not known
• Extracorporeal Carbon Dioxide Removal Physiology and Pathophysiology is only partially understood
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Kolobow et al Trans. Am. Soc. Artif. Intern. Organs. 1977. 23: 17
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6 4 2 0,40
20
40
60
80
100
Gas Flow Membrane Lung (l/min)
VCO2 Membrane Lung %
VCO2 Natural Lung %
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What influences the respiratory drive in COPD pts undergoing PECOR?
0
5
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40 45 50 55 60 65
EAdipeak
(μV)
PaCO2 (mmHg)
4
3
2
1
1) GF 10 L/min, VCO2ML 134 mL/min2) GF 5 L/min, VCO2ML 108 mL/min3) GF 2.5 L/min, VCO2ML 83 mL/min4) GF 0 L/min, VCO2ML 0 mL/min
R² = 0.96
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What influences the respiratory drive in ARDS pts undergoing ECMO?
R² = 0,1906
0
5
10
15
20
25
30,0 35,0 40,0 45,0 50,0 55,0
EAdipeak
(μV)
PaCO2 (mmHg)
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Does negative intrathoracic pressure favors lung edema ?
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Annals ATS aug 2013
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