CONCLUSIONS: Protective mechanical ventilation strategies were routinely used in high-volume extracorporeal membrane oxygenation centers. However, higher positive end-expiratory pressure levels during the first 3 days on extracorporeal membrane oxygenation support were independently associated with improved survival. Further prospective trials on the optimal mechanical ventilation strategy during extracorporeal membrane oxygenation support are warranted. 5 ECMO Centrum Karolinska
Prone positioning
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Recruitment
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HFO A randomised controlled trial and cost-effectiveness analysis of high-frequency oscillatory ventilation against conventional artificial ventilation for adults with acute respiratory distress syndrome. The OSCAR (OSCillation in ARDS) study Authors: Lall R, Hamilton P, Young D, Hulme C, Hall P, Shah S, Journal: Health Technology Assessment Volume: 19 Issue: 23 Conclusions The use of HFOV had no effect on 30-day mortality in adult patients undergoing mechanical ventilation for ARDS and no economic advantage. We suggest that further research into avoiding ventilator-induced lung injury should concentrate on ventilatory strategies other than HFOV. 8 ECMO Centrum Karolinska
Low tidal volume and plateau pressure
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Muscle relaxation
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Tidal volume doesn´t make healthy lungs Just because we get bigger tidal volume the lungs does not get healthy
BUT
Healthy lungs makes bigger tidal volume
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Lung recovery is a biological process High PEEP, Prone positioning, Recruitment, HFO, Low tidal volume, Low plateau pressure, Muscle relaxation
Increased risk for mortality … A tendency if introduction of VV ECMO (p=0.073) SAPS 3 score (p=0.025) Vasoactive Inotropic Score (p=0.038)
At 1-year follow-up … The number of affected organ systems showed impact (p=0.014)
Risk score models (in many cases based on Physiology) should not be used to deny patients from treatment.
! Risk score models if used as an ECMO criterion may (at this point) create more deaths than the illness itself! 15
Why do they die The patients don’t die from lack of lung recovery
They die from complication as brain bleedings-infarcts fungus and uncontrolled infections multiple brainstem infarctions herniation and multiple brain haemorrhages cerebral infarct and no infectious control
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During the H1N1 epidemic 2009-10 The first 5 patient in ICU treatment in Sweden ended up in an ECMO machine Partly because of too restricted ventilatory treatment, we had to tell the ICUs to just increase the pressure in the ventilator up to 45/20 because of lack of beds most of these patients survived anyhow.
13 patient vent into ECMO with 12 survival 92% surviving Totally in Sweden 32 patient died in H1N1
3 / million people
Most of them died at home because the health care system didn´t want them in to the hospital 17 ECMO Centrum Karolinska
ECMO as a tool for recovery not a treatment Two major types of lung injury : Wet lung with major capillary leacage Consolidated lung with cell infiltrate
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What to do with the lungs
Should we let the lungs collapse totally or try to keep some tidal volume open or recruitment to keep as much open as possible
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Capillary leakage Many patient has capillary leakage and we keep them sedated for 5-6 days with moderate high vent settings, just not to loose the to much of the tidal volume We use CVVDHF on more or less every patient to dry them out.
After that we lower the vent settings to 25/8 FiO2 0,4 20 ECMO Centrum Karolinska
Decision to wake the patient We decrease the sedation as much as possible Morphine Clonidine – Precedex
The best sedative is a low carbon dioxide pCO2 < 35mm Hg 21 ECMO Centrum Karolinska
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The wet lung Mostly 3-6 days for the plasma leakage to stop and then it will open up within 10-14 days and will recover very quickly
ECMO machine is just a tool to keep the patient alive during this period
Probably not so important how we treat the patient, unless we treat number on the screen and use extreme ventilation pressures
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The consolidated lung Consolidated stiff lungs totally occupied with cells It’s not possible to force them to open up No need for high very PEEP with a dry patient No need for high Peak pressure The elasticity is very low for several month The lungs will not open up until nearly all the cells is gone
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Tidal volume 53 days on ECMO Hemophilus Influenza pneumonie 400
350 300
ml
250 200 150
100 50 0
1
4
7
10
13
16
19
22
25
28
31
ECMO day 25 ECMO Centrum Karolinska
34
37
40
43
46
49
52
Tidalvolymer longrun ECMO Staphylococcus with PVL-toxin
Viktor 45 days with saturation of 65% Total 68 days on ECMO
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The dynamic process Total lung capacity relatively normal values after ALL with PCP pneumonia
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Longrun ECMO
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Mike Hines Houston 41 patients
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The underlying disease Is the only thing that matters
Decide the outcome If we can keep the infections under control
Be awake Wait for the recover without doing harm
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Ventilation
Relatively low pressure support ventilation with moderate peep. 25/8 mm Hg
Awake patient and Comfort is important 33 ECMO Centrum Karolinska
Conclusion In a longrun ECMO The ventilation strategy is not so important - but don't think you can break up the lungs
- recruitment is no longer possible - comfort is important to be able to have awake patient - the ECMO pump is your best friend don´t do everything to get rid of the pump It´s the underlying disease decide the outcome and not our treatment unless we behave stupidly 34 ECMO Centrum Karolinska
59 year old woman 229 days on ECMO transplanted and survived
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The worst I have seen and don´t understand 40 year old man from south Ireland on HFO in 4 weeks CDP
34 cm H20
Delta –P
134 cm H20
Frequences
3 Hz not even HFO just ventilation in180 breath/min
