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Extracorporeal CO2 Removal in ARDS
Antonio Pesenti University of Milano Bicocca Italy
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HISTORY First RCT on ECMO in ARDS.
No MV protocol during ECMO, only a generic indication of reducing inspiratory pressure and FiO2
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Adult respiratory distress syndrome (ARDS): why did ECMO fail
Adult respiratory distress syndrome (ARDS): why did ECMO fail? Kolobow T, et al Int J Artif Organs ;4:58 We believe severely diseased lungs have a chance to heal only if the environment remains conducive to the healing of the lung. This environment does not consist of high airway pressures, high tidal volumes, high PEEP, high FiO2……..
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Artificial Lung From Oxygenators: Buying time with artificial lungs To
Zapol WM, Kits RJ, NEJM 1972; 286 (12) To Artificial lungs: Resting the lung Gattinoni L 1976? Personal Communication
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NEJM 2000; 342:1301
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SPECIFIC HYPERVENTILATION
VE (L/min) FRC RATIO NORMAL 2500 < 7 < 2.8 ARDS 1000 > 15 > 15
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100 X 100 VA (actual) VA (control) 50 50 100 VCO2 (CDML) VCO2 (Total)
MECH. VENTILATION THEORETICAL SPONT. VENTILATION VA (actual) VA (control) X 100 50 50 100 VCO2 (CDML) VCO2 (Total) X 100
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Extracorporeal CO2 removal
Reducing ventilation anywhere down to 0 according to the proportion of VCO2 removed No ventilation , no VILI
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OXYGENATION FiO2 =1.0 250 mL min-1 VO2 7000 mL min-1 250 PBF mL min-1
Sata 98% VO2 250 mL min-1 PaO2 110 mmHg Hb 15 g Satv 82% PvO2 47 mmHg CO2 cont 52 mL PvCO2 43 mmHg CO2 REMOVAL VA 9500 mL min-1 VCO2 200 mL min-1 1100 mL min-1 PBF CO2 cont 34 mL PaCO2 15 mmHg Gattinoni et al., International Anesthesiology Clinics, 1983; 21:
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The technique seems to prevent the pulmonary barotrauma and extrapulmonary derangements caused by conventional mechanical ventilation 12
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ECMO CRITERIA + TSLC < 30 cmH2O 43 patients 21 survivors (49%)
LFPPV ECCO2R IN SEVERE ACUTE RESPIRATORY FAILURE GATTINONI et al: JAMA 1986 ECMO CRITERIA + TSLC < 30 cmH2O 43 patients survivors (49%) Mean by-pass length: Survivors ± 3.5 days NonSurvivors ± 6.6 days Bleeding: 1800 ± 500 ml/day
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Pumpless extracorporeal lung assist and adult respiratory distress syndrome Reng M et al., The Lancet 2000; 356 (15)
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PaCO2 VE FROM TO 8 patients 72 hr AVCO2R 90.8 ± 7.5 6.92 ± 1.6
Total extracorporeal arteriovenous carbon dioxide removal in ARF: a phase I clinical study Conrad S et al. ICM 2001; 27: 1340 8 patients 72 hr AVCO2R PaCO2 VE FROM 90.8 ± 7.5 6.92 ± 1.6 TO 51.8 ± 3.1 3.0 ± 0.53
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Critical Care 2006, 10:R151 18
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Anesthesiology. 2009 ;111: 826 PaCO2 (mmHg) Arterial pH * * * * * * *
baseline T0 T24 T48 T baseline T0 T24 T48 T72 Anesthesiology ;111: 826 20
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Arteriovenous extracorporeal respiratory support
Implementation
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Vv ILA with a pump
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The A Lung
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PALP System
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Extracorporeal CO2 Removal Physiological Side Effects
Decreased PA O2: ( Due to decreased QR) Decreased TV - Decrecruitment Higher PEEP equal Paw Ineffective Coughing ( ?)
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Marcolin R et al Trans Am Soc Artif Intern Organs 1986
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Marcolin R et al Trans Am Soc Artif Intern Organs 1986
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Trans Am Soc Artif Intern Organs 1986
Marcolin R et al: Trans Am Soc Artif Intern Organs 1986
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What influences the respiratory drive in COPD pts undergoing PECOR?
GF 10 L/min, VCO2ML 134 mL/min GF 5 L/min, VCO2ML 108 mL/min GF 2.5 L/min, VCO2ML 83 mL/min GF 0 L/min, VCO2ML 0 mL/min 4 3 2 1
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What influences the respiratory drive in COPD pts undergoing PECOR?
4 3 2 1 GF 10 L/min, VCO2ML 134 mL/min GF 5 L/min, VCO2ML 108 mL/min GF 2.5 L/min, VCO2ML 83 mL/min GF 0 L/min, VCO2ML 0 mL/min R² = 0.96
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Gas Flow Membrane Lung (l/min)
100 80 60 40 20 VCO2 Natural Lung % VCO2 Membrane Lung % 6 4 2 0,4 Gas Flow Membrane Lung (l/min) 33
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What influences the respiratory drive in ARDS pts undergoing ECMO?
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Extracorporeal CO2 Removal Physiological Side Effects
Decreased PA O2: ( Due to decreased QR) Decreased TV - Decrecruitment Higher PEEP Maintain Paw Ineffective Coughing ( ?)
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PAO2= FiO2 *713 - ( PaCO2/R) FiO2 1 PACO2 = 35 mmHg PAO2 300 mmHg 0.5
AIR PAO2 100 mmHg 0.5 1 R
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Cereda M et al. Chest 1996; 109: 480
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FUTURE VILI PREVENTION: THE IDEAL TOOL
Peripheral low flow cannulation ml/ min blood flow 50-80 % total CO2 production Regional anticoagulation Simple Safe circuitry ( CVVH) 38
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Zanella A et al
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Total CO2 elimination by a membrane lung
200 Δ 69% 180 160 Δ 27% 140 Δ18% 120 VCO2 (ml/min) 100 80 60 VCO2 standard conditions 40 VCO ALCOR 20 1 2 3 4 5 6 Acid infusion (mmol/min) 40
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ECLA: different techniques for different goals
Rescue of most severe hypoxemia ARDS Hyper protective ventilation Alternative to invasive ventilation ARDS, COPD
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Extracorporeal lung Assist 3 ALTERNATIVE TO VENTILATION
BLOOD FLOW UNDEFINED SOUND PATHOPHYSIOLOGY
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The three evils of MECHANICAL VENTILATION
VILI VAP SEDATION
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Extracorporeal support rationale
“... the best therapeutic strategy, to reduce the risk of new pneumothoraces and to stop the air leak, would be to dispense with mechanical ventilation or any form of positive airway pressure. Spontaneous breathing could be maintained by supplementing the spontaneous CO2 clearance with partial extracorporeal CO2 removal.” Pesenti A., et al: Percutaneous Extracorporeal CO2 Removal in a Patient with Bullous Emphysema with Recurrent Bilateral Pneumothoraces and Respiratory Failure. Anesthesiology 1990; 72:
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