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Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano

Management of native lung on ECMO. Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano Disclosure: none. The Oxygenator in Venovenous ECMO. Brodie D, Bacchetta M. N Engl J Med 2011;365:1905-1914. OXYGENATION FiO 2 =1.0 250 mL min -1. VO 2.

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Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano

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  1. Management of native lung on ECMO Roberto Fumagalli OspedaleNiguardaCa’Granda UniversitàdegliStudi Milano Bicocca Milano Disclosure: none

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

  3. OXYGENATION FiO2=1.0250mLmin-1 VO2 7000mLmin-1 Sata98% 250 mLmin-1 PBF PaO2110mmHg Hb15g Satv82% PvO247mmHg CO2cont52mL PvCO243mmHg CO2REMOVAL VA 2-4 Lmin-1 VCO2 200 mLmin-1 1100mLmin-1 PBF CO2cont34mL PaCO215mmHg Gattinonietal.,EuropeanAdvancesinIntensiveCare,1983;21:97-117

  4. ECMO mathematicalmodel 100 Steadystate 95 90 Shunt40% 85 Shunt50% 80 Shunt60% 75 ArterialOxygenSaturation(%) 10 20 30 40 50 60 70 ECMOBloodFlow(%CO)

  5. gasflow10l/min EConset 4 110 50 49 48 47 46 45 44 43 42 41 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 PaCO2 VE PaCO(mmHg) VE(mL*min) -1 2 (mmHg) 0 6 12 18 24 30 36 42 48 54 60 66 72 Time(h)

  6. BEWARE pH PCO2!! –RR(always) –TV(almost always) –I/E( watch out) •Guidedby: –EndTidalCO2 –ABG •in10’

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

  8. BE HAPPY • Pplat<30 • TV<6ml/Kg or even lower Rate: under debate: 3-10 bpm NOGOOD BETTER

  9. Ventillatory strategies in ECMO Recruiter NonRecruiter

  10. lungrestsettingswere: -peakinspiratorypressure20–25, -positiveendexpiratorypressure10–15, -rate10, -FiO20・3.

  11. Minute ventilationwasthenreduced by adjustingfrequency and inspiratorypressure. PEEP wasincreased to ventilate the patient with the leastpossiblemechanical stress whilemaintaining a sufficientlevel of oxygenation(oxygensaturation by pulseoximetry [SpO2] ≥90%).

  12. Ventilatorsettingswerereduced to restsettingsassoonaspossibleaftertransport to Stockholm and whenstable on by-pass. Peakinspiratorypressureswereadjusted to 20-25 cm H20, PEEP5-10 cm H20 and FiO2 0.4.

  13. NonRecruiterstrategy In33patients(49%),asecond access cannulawasneededtoaugment ECMOsupport.

  14. NonRecruiterstrategy •LowPEEP(5-10) •LPS –PSV •HighBloodFlow –II°drainagecannula •NOPNX •PulmonaryHypertension –V-Abypass? B.F.

  15. Recruiterstrategy • • • • RMs PEEPTitration SIGH PNX?

  16. Openingandclosingpressures Paw>35 50 cmH2O tofullyrecruit 40 30 20 10 0 Opening pressure Closing pressure % 0 5 101520253035404550 Paw[cmH2O] Crottietal.AmJRespirCritCareMed2001

  17. ModernPEEPTitration 15 12 10 10 7

  18. Effectsofperiodiclungrecruitmentmaneuversongasexchangeand respiratorymechanicsinmechanicallyventilatedARDSpatients. G.Foti,M.Cereda,M.E.Sparacino,L.DeMarchi,F.Villa,A.Pesenti IntensiveCareMed(2000)26:501-507 Pressionedireclutamento Sigh (1 ogni 3 min) SIGH ↑Oxygenation ↓Qva/Qt

  19. Always keeping in mindthat Packer et al Crit Care Med 1993;31:131-143

  20. SPECIFIC HYPERVENTILATION VE (L/min) FRC RATIO NORMAL 2500 7 2.8 ARDS 500 12 24

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

  22. Normalsheepsrandomlyassigned to 3 groups: • A: control MV 48 hrs • B: PIP 50 cm H2O RR 1-3 bpm • C: PIP 50 cm H2O RR 12 bpm CO2 3.8 Kolobow T, Moretti MP , Fumagalli R et al AmRevRespDis 1987, 135: 312-315

  23. Kolobow T, Moretti MP , Fumagalli R et al AmRevRespDis 1987, 135: 312-315

  24. Spontaneous breathing inARDS spontaneousbreathing controlledventilation,NMBA

  25. Thelungrestconcept Controlofbreathingusingan extracorporealmembranelung KolobowT,Gattinonietal.,Anesthesiology,1977;46:138-141

  26. The most appropriate ventilatorsettings for patients with severe ARDS who are undergoing ECMO are unknown.

  27. Wheneverpossible, weaim for limitation of pressure and set respiratoryratesthat are atleastasrestrictiveasthosedescribedabove, along with tidalvolumesthat are typicallymain- tainedbelow 4 ml per kilogram of predicted body weight, to minimize the potential for ventilator- associatedlunginjury. Whatever the approach, applyingadequate PEEP isimportant to maintainairwaypatencyat the lowlungvolumesattained with thesesettings.

  28. THANKS

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