ECMO AND ECCO2R THE

FUTURE MANAGEMENT
IN ARDS
ZUSWAYUDHA SAMSU
STAF ANESTESI DAN PERAWATAN INTENSIF PASCA BEDAH
RS JANTUNG HARAPAN KITA
 ACUTE RESPIRATORY FAILURE
Pulmonary Dysfunction HYPERCAPNIC
HYPOXIC
RESPIRATORY FAILURE
RESPIRATORY FAILURE
AaDO2 , TLc , VA COPD, BRONCHIOLITIS
PNEUMONIA, ARDS
OBLITERANCE
LUNG FIBROSIS

Ability to Compensate Increased Work of Breathing

Hypoxemia Hypercapnia

Drive of ECMO Positive

Drive of
Breathing &ECCO2R Pressure ECCO2-R
Breathing
Ventilation

VILI & MODS

 ACUTE RESPIRATORY DISTRESS
SYNDROME – RADIOLOGIC IMAGING
 ACUTE LUNG INJURY - DEFINITON

Acute Lung Injury :

• PaO2 /FiO2 < 300
• Bilateral Pulmonary infiltrates

ARDS
• Acute Lung injury with ratio of 200

European-American Consensus conference 1994

 ACUTE RESPIRATORY DISTRESS SYNDROME
Timing Within 1 week a known clinical insult or new/worsening respiratory
symptoms

Chest Bilateral opacities – not fully explained by effusions, lobar/lung collapse,

Imaging or nodules

Origin of Respiratory failure not explained by cardiac failure or fluid overload

Edema
Need objective assessment (echocardiography) to exclude hydrostatic
edema if no risk present

Mild Moderate Severe

Oxygenation 200<PaO2/FiO2 <300 100<PaO2/FiO2 <200 PaO2/FiO2 <100

PEEP/CPAP >5cmH20 PEEP >5cmH20 PEEP >5cmH20

Ranieri VM, Thompson BT, Rubenfield G et al, The ARDS Definition Task Force
JAMA, June 20, 2012, Vol 307-23
“HALLMARK” OF ARDS

Diffuse Alveolar
Damage
 ETIOLOGY OF ARDS

TREATMENT • ETIOLOGIC
OF ARDS • SYMPTOMATIC
 HIGH RISK PATIENTS TO DEVELOP
ARDS, WHO ARE THEY?

ALL ICU PATIENTS HAVE TO BE

CONSIDERED AT RISK TO DEVELOP LUNG
FAILURE

INFLAMATION SURGERY SEDATION :

SEPSIS PROPOFOL,
PANCREATITIS MORPHINIC, NMBA
ANTIBIOTIC
ELECTROLYTES NON OPTIMAL
MEDICAL HISTORY IMBALANCE VENTILATOR SETTING
COPD – CANCER – HYPERGLYCEMIA
IMMUNE DEFICIENCY TRANSFUSION
 ???

-How well do we recognize patients

FULLFILLING ” Berlin Criteria ?

-Did Clinician recognition of ARDS

impact on Patients Management ?
 CONSEQUENCES ON
UNDER- RECOGNITION OF ARDS
ARDS has relatively high incidences under treated.
• Geographic variation.
• ARDS is under recognized.
• ARDS is under treated.
• Patients in whom ARDS not clinician diagnosed, less likely to receive
Evidence - based intervention
• Higher PEEP
• Prone positioning
• Neuromuscular blockage
-Overall 40% ARDS still die
 LUNG SAFE STUDY

Burden of severe Acute Respiratory Failure .

• ARDS versus other causes .

Contribution of ARDS ( base on Berlin Definition )

• Mortality according to ARDS severity.
• Natural history of ARDS.
• Therapeutic resources utilization ( Rescue theraphy ).
• Use of non invasive ventilation management of ARDS.
• Clinical recognition of ARDS .
CURRENT DIAGNOSTIC PRECISION OF
ARDS

ARF
ARDS
PATIENTS ARF PATIETNS WITH
PATIENTS
WITHOUT ARDS
DIAGNOSED
ARDS
 ECMO CRITERIA
CONTINUE
P/F <80 NO PREVIOUS
MANAGEMENT

YES

INITIATE ECMO
EVALUATION

P/F <80 for >6hours ECMO if no

P/F <50 for >3hours exclusion criteria
AS ECMO EVOLVED TECHNOLOGY HAS
ITS USE HAS EXPANDED SIGNIFICANTLY IN
PATIENTS WITH SEVERE
FORM OF RESPIRATORY FAILURE.

ECLS for Respiratory failure:

• ECMO (Extra Corporeal Membran Oxygenator)
• Respiratory failure to provide adequate oxygenation.
ECCO2R( Extra Corporeal CO2 Removal )
• Chronic ventilatory failure : COPD.
• Acute ventilatory failure to prevent intubation.
• To minimize VILI ( ventilator induced lung injury )
ECCO2R VS VV-ECMO
 VV ECMO

ECLS should be considered when the

RISK of MORTALITY is 50% or
greater , and is indicated when the is
80 % or greater.
• 50 % mortality Risk : -PaO2 / FiO2 < 150 on FiO2 >
90 %
• Murray score 2-3 .
• 80% mortality Risk : -PaO2/ FiO2 < 80 on FiO2
>90% .
• Murray score 3-4 .
EXTRACORPOREAL LIFE SUPPORT IN
ARF
 CONSIDERATION

What are the OUTCOMES after

VV-ECMO

Better select patients suitable for

ECMO
ACADEMIC INTEREST IN ECLS HAS
GROWN SIGNIFICANTLY
CLINICAL USE OF ECLS HAS GROWN
SIGNIFICANTLY – ASSOCIATED WITH
SIGNIFICANT SIDE EFFECT!
 THE VV ECMO – MAIN PRINCIPLE

To replace
pulmonary function.

To allow the Lung to

rest

To allow healing of
the Lung
PHERIPERAL VA ECMO IS NOT
INDICATED FOR ARF - WHY?

• Flow Competition in the Aorta

• Heart vs ECMO Pump
• If Pulmonary Function is Impaired
• The Harlequin Syndrome
• Blue Head : deoxygenated blood
directed to the upper part of the
body
• Red Legs : Hyper oxygenated
blood in the lower part of the
body
• Not Possible to rest the lungs
• Vt, Pplat and FiO2 cannot be reduced
 PHERIPERAL VA ECMO IS NOT
INDICATED FOR ARF - WHY?

VA ECMO increases LV Afterload

• Risk of Myocardial damage / stunning

Complications associated with the arterial

line in VA femoro-femoral ECMO
• Leg ischemia
• Arterial Embolism
• Massive arteriage hemorrhage
MECHANICAL VENTILATION OF THE
PATIENT UNDER VV-ECMO

Main Objective : Minimalize VILI

• Pplat 20-24 cm H2O
• Vt Set at 1-4mL/Kg of Ideal Body Weight (if assist controlled mode used)
• BiPAP or APRV Mode Possible
Other MV Settings
• PEEP increased to recruit the lungs  12-16 cm H2O
• FiO2 <50%
• Respiratory rate 15-25
Patients often deeply sedated and paralyzed at the initial phase
ECMO IN ADULT WITH SEVERE
RESPIRATORY FAILURE : A MULTICENTER
DATABASE
• ELSO Registry from 1986-2006
• 1473 patients from severe respiratory failure
• Median age was 34 years
• Most patients (78%) supported with VV ECMO
• 50% survived to hospital discharge

Brogan VT et al. Intensive Care Med (2009)

 EFFICACY AND ECONOMIC ASSESSMENT OF
CONVENTIONAL VENTILATORY SUPPORT VERSUS ECMO
FOR SERVERE ADULT RESPIRATORY FAILURE (CESAR) A
MULTICENTRE RANDOMISED CONTROLLED TRIAL

• UK 2001-2006
• ECMO provided only at the Glenfiled Hospital, Leicester
• Entry Criteria
• Adult patients (18-65 years)
• Severe but potentially reversible ARDS
• Murray score >3.0 or
• Uncompensated Hypercapnia : pH <7.20

• Primary Outcome Measure

• Death or severe disability 6 months

Gles P, Mugford M, Wilson A et.al – Lancet 2009

 ECCO2REMOVAL : THE BASIC

CO2 is more soluble and diffuses more easily in blood

relative to O2.

LOW FLOW : to remove all metabolically produced CO2 ,the

blood flow required an efficient membrane is only 20 % of
total cardiac out put.

The low flow requirement = allowed the used of smaller

cannulas.
 ECCO2 REMOVAL : INDICATIONS

Late ARDS with CO2 retention .

Alternative to mechanical ventilation in

severe hypercapnic respiratory failure :
• COPD patients
• Cystic fibrosis
• Other chronic Lung disease
THE BEGINNING OF ECCO2R
PROTECTIVE VENTILATORY STRATEGY
IN ARDS

• Low VT 6 mL/kg PBW

• P plat limit to 30 cmH2O
• Driving Pressure limit to 14 cm H2O
6 ML/KG TIDAL VOLUME, DOES IT
ALWAYS SAFE?
SAFE THRESHOLD OF PLATEAU
PRESSURE?
SAFE THRESHOLD OF DRIVING
PRESSURE?
 STRATEGY TO MINIMALIZE VILI IN
ARDS
TIDAL VOLUME BELOW NORMAL 6 mL/kg (1-3 mL/KG)
ULTRA-PROTECTIVE VENTILATION

ECCO2R

HYPERCAPNIA & RESPIRATORY ACIDOSIS

POST-HOC ANALYSIS
ULTRA-PROTECTIVE VENTILATION IN
SEVERE ARDS
ULTRA-PROTECTIVE VENTILATION IN
SEVERE ARDS
LOW FLOW (V-V) ECCO2R IN ARDS
LOW FLOW (V-V) ECCO2R IN ARDS
METABOLIC EFFECT OF
ULTRAPROTECTIVE MV
ULTRAPROTECTIVE VENTILATION IN
MODERATE ARDS
ULTRAPROTECTIVE VENTILATION IN
MODERATE ARDS

COMPLICATIONS

1. Transfused patients (2 u RBC/pt) : 4 on

day 1, 2 on day 2m 1 on day 3
2. Intravascular Hemolysis (1 Patient)
3. Severe Hypoxemia 6 patients (4 prone, 2
ECMO)
 MECHANISM OF HYPOXEMIA WITH
ECCO2R

REASON FOR HYPOXEMIA

1. GRAVITATIONAL ATELECTASIS
2. ABSORPTION ATELECTASIS
3. OPENING PRESSURES
4. ALVEOLAR PAO2 AND RESPIRATORY QUOTIENT

Luciano Gattinoni - Ultra-protective Ventilation and Hypoxemia

ECCO2 REMOVAL : POTENTIAL
INDICATION
 CONCLUSION

ECMO ,ECCO2 Removal has tremendous

potential for treatment of patients with ARDS.

Should be used in experience center.

Think of ECMO/ECCO2 as bridge…

• A BRIDGE to now where is an OPTION …