Hospital Authority Convention 2015 ECMO/ ECCO2R + Ultra-protective Lung Ventilation Dr. Yan Wing Wa Department of Intensive Care Pamela Youde Nethersole Eastern Hospital
19 May 2015 1
Scope
Two forms of ECMO
ECMO - high flow Extracorporeal CO2 Removal (ECCO2R) - low flow
Roles in management of ARDS?
Types ECCO2R available
2
Acute respiratory distress syndrome (ARDS)
Injured lung need rest till recovery but Injured lung need to maintain adequate O2 saturation More severe injury need more vent. pressures, PEEP, FiO2
More ventilator induced lung injury Oxygen toxicity Vicious cycle
Protective Lung Ventilation (PLV) Tidal volume 6ml/kg vs. 12ml/kg
Anesthesiology 2009;111:826-35
Ultra-Protective Lung Ventilation
2 Forms of ECMO
Extracorporeal membrane oxygenation (ECMO)
High flow (4 – 6 L/min) Both oxygenation & CO2 removal
Extracorporeal CO2 removal (ECCO2R)
Low flow (0.5 to 1 L/min) Only CO2 removal
Extracorporeal flow needed
Flow ml/min
10000
ECMO
1000
ECCO2R
100
CRRT
IHD
10
7
Physiology Of O2 delivery
O2 consumption ~ 240 ml/min Amount of O2 added to the blood via ECMO ~ 40-60 ml/L
1.34 * Hb * (SoutO2 – SinO2)
4 – 6 L/min blood flow is needed
Physiology of CO2 removal
CO2 generation ~ 200 ml/min Amount of CO2 stored in blood ~ 500 ml/L Achieved adequate CO2 removal with < 1L/min
ECCO2R
Gattinoni L,et al. Low-frequency positive pressure ventilation with extracorporeal carbon dioxide removal : an experimental study. Anesth Analg 1978, 57:470-477
9
Randomized Control Trials
Fitzgerald M et al. ECCO2R for patients with acute respiratory failure secondary to the ARDS: a systematic review. Critical Care 2014,18:222
Outlook of ECCO2R
No definitive conclusions can be drawn at this stage for ARDS
Possible other roles
Sample sizes too small Negative RCT No mortality benefit Do have improvements in PaCO2, lower tidal volume, plateau pressure, +/-ventilator-free day COPD failing NIV Status asthmaticus Bridge to lung transplant
Complications
Cannulation risk similar to renal replacement therapy Circuit thrombosis, bleeding
Clinical Trials (ARDS) Trial
Indication
Type
Number of subjects
Estimated End
SUPERNOVA ARDS Pilot-toPivotal
Ultraprotective ventilation in Moderate to Severe ARDS
Prospective, ESICM-led
Single-arm Pilot 100
Q3 2019
REST ARDS Pilot-to-Pivotal
Ultraprotective ventilation in Moderate to Severe ARDS
Prospective, UK funded, consortium-led
Singapore ARDS Pilot
Ultraprotective ventilation and recruitment in Moderate to Severe ARDS
Prospective, Investigator-Initiated Pilot RCT
50 (25/25)
Q1 2016
HAVAnA Trial (The Netherlands)
Effects of induced hyperthermia with novatherm and iLAactivve minilung in Moderate ARDS
Prospective, Feasibility Study
30
Not yet recruiting
ALung ARDS Feasibility
Ultraprotective ventilation in Moderate to Severe ARDS
Prospective, Investigator- Initiated Feasibility Study
15
Q4 2014
PARSA Trial (France)
Pulmonary and renal support for adult patients experiencing both ARDS and acute renal failure
Prospective, Single-arm Feasibility Study
10
Recruiting
Pivotal 2,050 Single-arm Pilot 40
Q4 2019
Pivotal 1,120
Types & Devices for ECCO2R
Arteriovenous CO2 Removal (AVCO2R)
Pumpless Extracorporeal Lung Assist (PECLA)
Venovenous CO2 Removal (VVCO2R)
Decap/Decap-Smart Hemolung iLA Activve Typical VV-ECMO set up
16
AVCO2R or PECLA
iLA Membrane Ventilator, Novalung, GmbH, Germany
17
AVCO2R or PECLA
Novalung: interventional Lung Assist (iLA) membrane ventilator Hemodynamic should be stable, with MAP >60mmHg Flowmeter monitoring is needed Risk of distal limb ischemia Indications
UPLV for ARDS Status asthmaticus Bridge to lung transplantation
18
19
Hemodec, Salerno, Italy
Allow CO2 removal + Renal Replacement Therapy Successful trials in adults and children *Terragni PP, Gattinoni L, Ranieri VM et al: Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal. Anesthesiology 2009, 111:826-835
20
Alung Technologies, Pittsburgh, USA
21
Venovenous CO2 Removal
Move gradually to VV-ECMO
22
Typical VV-ECMO circuit
Jugular vein
Oxygen Membrane lung Circuit pump
Femoral vein
24
Thank you.
25
