Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano
description
Transcript of Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano
![Page 1: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/1.jpg)
Roberto FumagalliOspedale Niguarda Ca’ GrandaUniversità degli Studi Milano BicoccaMilanoDisclosure: none
Management of native lung on ECMO
![Page 2: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/2.jpg)
![Page 3: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/3.jpg)
The Oxygenator in Venovenous ECMO.
Brodie D, Bacchetta M. N Engl J Med 2011;365:1905-1914
![Page 4: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/4.jpg)
OXYGENATIONFiO2 =1.0 250 mL min-1
VO2250
mL min-1
Sata98%
PaO2110 mmHgHb 15 gSatv82%
7000 mL min-1
PBF
CO2 REMOVALVA 2-4 L min-1
VCO2200
mL min-1
CO2 cont 34 mL
PaCO215 mmHg
PvO247 mmHgCO2 cont 52 mLPvCO243 mmHg
1100 mL min-1
PBF
Gattinoni et al., European Advances in Intensive Care, 1983; 21: 97-117
![Page 5: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/5.jpg)
Arte
rial O
xyge
n Sa
tura
tion
(%)
Steady state100
ECMOmathematical model
ECMO Blood Flow (%CO)
10 20 30 40 50 60 70
95
90Shunt 40%
85Shunt 50%
80Shunt 60%
75
![Page 6: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/6.jpg)
VE
(mL
*min
)
PaCO
(mm
Hg)
(mm
Hg)
-12
1 10 4
PaCO2
VE
gas flow 10 l/min EC onset
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
50
49
48
47
46
45
44
43
42
41
0 6 12 18 24 30 36 42 48 54 60 66 72
Time (h)
![Page 7: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/7.jpg)
BEWARE pH PCO2 !!
– RR (always)– TV (almost always)– I/E ( watch out)
• Guided by:– EndTidalCO2– ABG
• in 10’
![Page 8: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/8.jpg)
FR = 30
Paw = [(30*1) + (15*1)] / 2 = 22.5
30
Mean airways pressure
FR = 15
Paw = [(30*1) + (15*2)] / 3 = 20
30
1” 1”
15
1” 2”
15
![Page 9: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/9.jpg)
BE HAPPY
• Pplat < 30• TV < 6 ml/Kg or even lowerRate: under debate: 3-10 bpm
NO GOOD BETTER
![Page 10: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/10.jpg)
Ventillatory strategies in ECMO
Recruiter Non Recruiter
![Page 11: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/11.jpg)
![Page 12: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/12.jpg)
lung rest settings were :- peak inspiratory pressure 20–25,- positive endexpiratory pressure 10–15,- rate 10,- FiO2 0・ 3.
![Page 13: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/13.jpg)
• Minute ventilation was then reduced by adjusting frequency and inspiratory pressure. PEEP was increased to ventilate the patient with the least possible mechanical stress while maintaining a sufficient level of oxygenation (oxygen saturation by pulse oximetry [SpO2] ≥90%).
![Page 14: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/14.jpg)
Ventilator settings were reduced to rest settings as soon as possible after transport to Stockholm and
when stable on by-pass. Peak inspiratory pressures were adjusted to 20-25 cm H20, PEEP5-10 cm H20
and FiO2 0.4.
![Page 15: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/15.jpg)
Non Recruiter strategy
In 33 patients (49%), a secondaccess
cannula was needed to augmentECMO support.
![Page 16: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/16.jpg)
Non Recruiter strategy• Low PEEP (5-10)• LPS
– PSV• High Blood Flow
– II° drainage cannula• NO PNX• Pulmonary Hypertension
– V-A bypass?
B.F.
![Page 17: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/17.jpg)
Recruiter strategy••••
RMsPEEP TitrationSIGHPNX ?
![Page 18: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/18.jpg)
%
Opening and closing pressures50
OpeningpressureClosingpressure
Paw > 35cmH2Oto fully recruit
0 5
40
30
20
10
010 15 20 25 30 35 40 45 50
Paw [cmH2O]Crotti et al. Am J Respir Crit Care Med 2001
![Page 19: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/19.jpg)
Modern PEEP Titration
10 1215
710
![Page 20: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/20.jpg)
Sigh (1 ogni 3 min)
Effects of periodic lung recruitment maneuvers on gas exchange andrespiratory mechanics in mechanically ventilated ARDS patients.
G. Foti, M.Cereda, M.E. Sparacino, L. De Marchi,F. Villa, A. PesentiIntensive Care Med (2000) 26: 501-507
Pressione di reclutamento
↑Oxygenation↓ Qva/Qt
SIGH
![Page 21: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/21.jpg)
Always keeping in mind that
Packer et al Crit Care Med 1993;31:131-143
![Page 22: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/22.jpg)
FRC VE (L/min) RATIO
NORMAL
ARDS
2500 7 2.8
500 12 24
SPECIFIC HYPERVENTILATION
![Page 23: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/23.jpg)
Hager DN AmJ Respir Crit Care Med :2005: 172: 1241
![Page 24: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/24.jpg)
• Normal sheeps randomly assigned 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 alAm Rev Resp Dis 1987, 135: 312-315
![Page 25: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/25.jpg)
Group A Group B Group C
Normal 5 - -
Light damage
1 - -
Moderate 2 1 1
Severe - 1 -
Very severe - 5 8
Kolobow T, Moretti MP , Fumagalli R et alAm Rev Resp Dis 1987, 135: 312-315
![Page 26: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/26.jpg)
Spontaneous breathing in ARDS
spontaneous breathing controlled ventilation, NMBA
![Page 27: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/27.jpg)
Control of breathing using anextracorporeal membrane lung
The lung rest concept
Kolobow T, Gattinoni et al., Anesthesiology, 1977; 46: 138-141
![Page 28: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/28.jpg)
• The most appropriate ventilator settings for patients with severe ARDS who are undergoing ECMO are unknown.
![Page 29: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/29.jpg)
Whenever possible, we aim for limitation of pressure and set respiratory rates that are at least as restrictive as those described above, along with tidal volumes that are typically main- tained below 4 ml per kilogram of predicted body weight, to minimize the potential for ventilator- associated lung injury. Whatever the approach, applying adequate PEEP is important to maintain airway patency at the low lung volumes attained with these settings.
![Page 30: Roberto Fumagalli Ospedale Niguarda Ca ’ Granda Università degli Studi Milano Bicocca Milano](https://reader035.fdocuments.net/reader035/viewer/2022062305/56816401550346895dd5a05e/html5/thumbnails/30.jpg)
THANKS