ECMO/ECCO2R in Acute Respiratory Failure...Influence of Sweep Gas Flow Schmidt et al, Intensive Care Med, 2013 25 30 35 40 45 50 55 60 65 70 75 50 60 70 80 90 100 110 120 130 140 150

[email protected] www.paris-ecmo.orgCardiology Institute [email protected] www.paris-tcsecmo.orgCardiology Institute

ECMO/ECCO2R in Acute Respiratory Failure

Alain Combes, MD, PhDCardiology Institute, Hôpital Pitié-Salpêtrière, AP-HP

Inserm UMRS 1166, iCAN, Institute of Cardiometabolism and Nutrition

Sorbonne Pierre et Marie Curie University, Paris, [email protected]


Conflict of interest

• Principal Investigator: EOLIA trial• VV ECMO in ARDS• NCT01470703 • Sponsored by MAQUET, Getinge Group

• Received honoraria for lectures from • MAQUET, XENIOS, BAXTER


ECMO/ECCO2RThe rationale…For ARDS patients…To decrease the intensity of MV?


The evolving paradigm…• ARDSnet strategy might not protect against tidal hyperinflation

• When Pplat remains >28-30 cm H2O • Further decrease of Vt to reduce VILI

• From 6 to <2 ml/kg IBW• To decrease Pplat <25 cm H2O• To decrease ∆P < 12-14 cm H2O• With sufficient PEEP to prevent lung derecruitment?

• To decrease RR to <20… <15… <10?????• Extracorporeal gas exchange for

• Blood Oxygenation/Decarboxylation• Decrease the intensity of MV…


What areECMO and ECCO2R?Same Technology

Different Objectives…


Membrane lung O2/CO2 transfer

O2 transferCO2 transfer

ECMO for oxygenation

ECCO2R for Decarboxylation


Influence of ECMO flow

Schmidt et al, Intensive Care Med, 2013

Adequate Oxygenation

Qecmo > 60% Qco

PaO2 mmHg

SaO2, %

PaCO2 mmHg


Influence of Sweep Gas Flow

Schmidt et al, Intensive Care Med, 2013

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ECMO and ECCO2R

ECMO• Large cannulas

• High extracorporeal flow• >5000 ml/min

• Large membrane oxygenator

• Full blood oxygenation

• Full blood decarboxylation

• High technicity, ECMO center

ECCO2R• Double lumen catheter• Low flow, respiratory dialysis

• 250-1000 ml/min

• Medium size oxygenator• No blood oxygenation• Partial blood

decarboxylation• Regular ICU


ECMO and ECCO2R…What is the Evidence?


Results of series of VV-ECMO in ARDS patients


The CESAR trial


• UK, 2001-2006

• ECMO provided only at the Glenfield 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





Time from randomization to death

Log rank p = 0.03







17 (25%)


Et al…


Et al…


• The French REVA Registry collected data of patients hospitalized in ICUs

• For H1N1-associated ARDS

• Analysis of factors associated with death among 123 patients who received ECMO

• Case-control study with matching on a propensity score to receive ECMO



Why early ECMO?



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MV >7 days before ECMO

P <0.005, log-rank


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500Before ECMO After ECMO

0 0

Driving Pressure Tidal Volume Plateau Pressure


Results ECCO2R seriesin ARDS patients



40 ECCO2R Strategy

39 Conventional Strategy




A Strategy of UltraProtective lung ventilation

With Extracorporeal CO2 Removal for

New-Onset moderate to seVere ARDS

The SUPERNOVA trial

Pilot feasibility and safety studyMarco Ranieri and Alain Combes, on behalf of


Flow chart

95 in the analysis

MAQUET

N=28

NOVALUNG

N=34

ALUNG

N=33


AT ENROLLMENT

• 95 patients in 7 countries• Belgium, Canada, France,

Italy, Germany, Netherlands, Spain

• 23 centers

• 3 [1-5] patients per center

• Male: 67%

• Age: 60±14

• SAPS II: 45.9 ±15.5

• SOFA: 7.4 ±3.2

• Bilateral opacities: 92 (97%)


Cause of ARDS (%)

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Pneumonia(bacterial)

Pneumonia(Flu)

Inhalation Otherpneumonia

Nonplumonary

sepsis

Pancreatitis Pulmonarycontusion

Extra-corporalcirculation

Other

82%


During run-in time (2 hrs)• Minute ventilation: 10.3±2.5

• VT: 6.1±0.7 (387.4±72.6)

• RR: 27.2±5.3

• PEEP: 12.1±4.3

• PIP: 34.6±7.0

• Pplat: 26.2±5.2

• DELTA P: 13.2±5.1

• FiO2: 60 [50-70]

• PF: 153±40

• pH: 7.3±0.1

• PCO2: 47.5±7.9

• Bicarbonate: 25.6±4.7

• Lactate: 1.6±1.1

• HR:92.3±21.8

• MAP: 76.5±11.4


Tidal Volume

98% REACHED THE TARGET OF4.0 ml/kg (+/- 20%)


PplatPplat decreased:

From 26±5 to 23±3, p<0.0173% had a decreased Pplat

Percentage of decrease: -11% [-20 to 0]


PEEPPEEP INCREASED:

From 12±4 to 14±4cmH2O,p<0.01(29±58 % baseline vs. 4 ml/Kg)


Driving PressureDeltaP decreased:

from 13±5 to 9±4 cmH2O, p<0.0133±16 % baseline vs. 4 ml/Kg


PaCO2

NO SIGNIFICANT CHANGES


pH



PaO2/FiO2



Survival at D28

69/95 = 73%


Probability of being on ECCO2R

ECCOR duration: 5 [3-8] days


Serious adverse events

2 patients• HEMORRAGIC SHOCK RELATED TO AN ARTERIAL

BLEEDING IN THE CAECUM, NO SURGERY BECAUSE OF THE LACK OF RESPIRATORY IMPROVEMENT IN THE LAST 3 WEEKS, MINIMAL DOSES OF ANTICOAGULATION BUT POSSIBLE PLATELETS DYSFUNCTION RELATED TO ECCOR

• CEFOTAXIM BLOOD LEVEL < 0,1 MG/ML


Device-related mechanical events

• PUMP CLOTTING: N=6• Change circuit ECCO2R n=1• Discontinue ECCO2R N=5

• DERECRUITMENT/HYPOXIA: N=2 • Increased VT

• HEMOLYSIS: N=3• HEMORRHAGE AT CANNULA INSERTION POINT: N=4• PNEUMOTHORAX: N=1• HYPOTHERMIA: N=1


“In God we (may) trust; all others

must bring data…”W. Edwards Deming

(1900-1993)


EOLIA: ECMO to rescue Lung Injury in severe ARDS


EOLIA: ECMO to rescue Lung Injury in severe ARDS


EOLIA… A new trial of ECMO

for severe ARDS249 patients randomized…

YESWECAN

YESWECAN


A Strategy of UltraProtective lung ventilation

With Extracorporeal CO2 Removal for

New-Onset moderate to seVere ARDS

The SUPERNOVA trial


Documents

ECMO/ECCO2R in Acute Respiratory Failure...Influence of Sweep Gas Flow Schmidt et al, Intensive Care Med, 2013 25 30 35 40 45 50 55 60 65 70 75 50 60 70 80 90 100 110 120 130 140 150