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Mechanical Ventilation in ECLS

Ravi S. Tripathi, MD

Ravi.tripathi@osumc.edu September 28, 2018

2 | Hill NEJM 1972

“At a by-pass flow of 3.0 to 3.6 liters per minute, oxygen tension increased from 38 to 75 mm of mercury, inspired oxygen concentration was reduced from 100 to 60 per cent, and peak airway pressure decreased from 60 to 35 cm of water. The shock-lung syndrome was reversed, and the patient recovered.”

3 |

“We conclude that ECMO can support respiratory gas exchange but did not increase the probability of long-term survival in patients with severe ARF.”

Zapol JAMA 1979

•  Nine medical centers •  Prospective, randomized trial •  Supported by NIH •  Excluded if duration of pulmonary

insult greater than 21 days

4

“Management on ECMO (including rest ventilator settings) was according to published institutional protocols.” •  Pressure Control Ventilation

•  RR=10

•  Peak Inspiratory pressure 20-25 cmH2O

•  Positive End-Expiratory Pressure 10-15 cm H2O

•  FiO2= 0.3

GL Peek. Lancet. 2009.

Ventilator-Induced Lung Injury

5 |

Volutrauma 6 ml/kg/PBW

Atelectotrauma

Higher Levels of PEEP

Biotrauma

6 | AS Slutsky & VM Ranieri. NEJM. 2013

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M Schmidt. Critical Care Med. 2015 M Schmidt. Critical Care Med. 2015

M Schmidt. Critical Care Med. 2015

Hemodynamics and PEEP

C. Guervillly, et al. Crit Care Med. 2012.

12 | AS Neto, et al. Intensive Care Med. 2016

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13 | AS Neto, et al. Intensive Care Med. 2016

14 |

AS Neto, et al. Intensive Care Med. 2016

FiO2 associated with mortality. Driving pressure independently predicts mortality.

15 | J Araos, et al. AJRCMM. 2018

16 | MM Hoeper, et al. Intensive Care Med. 2013.

Fraction Inspired of Oxygen

17 |

§  Minimize oxygen toxicity

§  Limits alveolar decruitment

§  Target SpO2 to 85%

§  VA-ECMO

Combes A et all. Curr Opin Crit Care. 2012 18 |

L Gattinoni, et al. Curr Opin Crit Care. 2017.