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Advanced Implication of ECMO for the Patient with

Severe Acute Respiratory Failure

H.T Tan M.D.����������

Outline

� History and Terminology� Introduction of ECLS� Severe Acute Respiratory Failure (ALI or ARDS)� ECLS for ARDS � Evidence Based Medicine� Local Experience

John Gibbon

� 1953�� � � � � � � � (CPB) � � � � � � � �

� � �

Terminology� 1970s : ECMO ������������������������, � �� �� �� � ” � � � �”� 1980s Kolobow : ECCO2-R (Extracorporeal carbon dioxide

removal)� 1987 Japanese : ECLA (Extracorporeal lung assist)

� 1989 Zwischenberger and Bartlett :� ECLS (Extracorporeal Life Support)������

� Prolong but temporary(1-30days) support of heart or lungfunction using mechanical devices

� ELSO (Extracorporeal Life Support Organization) � �

Robert Barlett

� “��������������������”� 1976, � � � � � � �

ECMO � � � � � � �

� � � � (MAS, PPHN and CDH)

� Name of baby “Esperanza”(Spanish for Hope)

Outline

� History and Terminology � Introduction of ECMO(ECLS)� Severe Acute Respiratory Failure (ALI or ARDS)� ECLS for ARDS � Evidence Based Medicine� Local Experience

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ECMO=ECLS

Extracorporeal Life SupportVA ( � - � � ) -ECMOVV ( � - � ) -ECMO

(��- � �)

VV (��-��) -ECMO

CPB(����)VS

ECMO(������������)

ECLS in critical care, 2005

VA-ECMOVS

VV-ECMO

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ECLS in critical care, 2005

VA-ECMO VV-ECMO

ECLS in critical care, 2005

Component of ECMO

� Membranous oxygenator( � � � )� Pump(� � �� )� Gas flow(� � CO2 and O2)� Heater( � � � � )� Cannule� Monitor� Circuit

Outline

� History and Terminology � Introduction of ECLS� Severe Acute Respiratory Failure (ALI or ARDS)� ECLS for ARDS � Evidence Based Medicine� Local Experience

Severe Acute Respiratory Failure

Acute Lung Injury(ALI)and

Acute Respiratory Distress Syndrome(ARDS)

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Acute Lung Injury� 1994 American-European Consensus Conference on ARDS

� Definition :� A syndrome of inflammation and increased

permeability that is associated with a constellation of clinical, radiologic, and physiologicabnormalities that cannot be explained by, but may coexist with, left atrial or pulmonary capillary hypertension”

Intensive Care Med 1994; 20:225–232

Acute Lung Injury

� Clinical Criteria � Acute onset of pulmonary failure(<7 days)� Hypoxia with a PaO2/FIO2 < 300 mm Hg� Bilateral chest infiltrates visible on a CXR� PCWP<18mmHg(or no clinical evidence ↑LAP)

� ARDS (severe form of ALI)� The same criteria, except PaO2/FIO2 < 200 mm Hg,

regardless of the PEEP on the ventilator support

Intensive Care Med 1994; 20:225–232

Lancet 2007; 369: 1553–65

Acute Lung injury

� Crude incidence 78.9 per 100,000 person-years� In-hospital mortality rate 38.5%, increased with

increasing age� Estimated 190,600 cases annually in US�

74,500 deaths and 3.6 million hospital days

NEJM 2005; 353:1685–1693

NEJM 2005; 353:1685–1693

ARDS

� High mortality rate 40 to 60% despite recent advanced treatment

� Severe ARDS� PaO2/FiO2<100 on FiO2 of 1.0� Alevolar-arterial gradient(A-aDO2)> 600mmHg� Transpulmonary shunt fraction>30% after optimal Tx� Higher mortality rate >80%

Chest. 1995;107:1083-1088NEJM. 1998;338:341-346

Am J Respir Crit Care Med. 1999;159:1849-1861NEJM. 2000;342:1301-1308Chest. 2000;117:1690-1696

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Ventilation Strategy

� Low Tidal Volumn Ventilation� Low TV 6ml/kg and plateau pressure<30cmH20 vs

TV 12ml/kg and plateau pressure<50cmH2O�Low TV with lower mortality

� Positive End-Expiratory Pressure(PEEP)� Optimal level of PEEP remain controversial� A recent study showed PEEP above the lower inflection point

(LIP+2cmH2O) and a TV of 5-8ml/kg with decreased mortality

NEJM. 2000;342:1301-1308Crit Care Med 2006;34:1311-1318

Am J Respir Crit Care Med 2005;172:1241-1245 Am J Respir Crit Care Med 2005;172:1241-1245

Ventilation Strategy

� Recruitment Strategies� No clinical study has clearly proven the effective for lung

protection and survival

� Mode of Ventilation� No clinical trial demonstrated any significant difference

between pressure-control and volumn-controlled ventilation

Treatment

� Inhaled Nitric Oxide� Recent meta-analysis confirmed short term improvement

in oxygenation without any influence on mortality but an increased risk of renal dysfunction

� Prone Position� Improvement in oxgenation and alveolar recruitment� But, no difference in mortality or complication� No significant survival advantages

BMJ 2007;334:79

Crit Care Med 1976;4:13-14Am Rev Respir Dis 1977;115:559-566

NEJM 2001;345:568-573

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Hemodynamic Management

� Negative Fluid Balance� ARDS Clinical Trials Network study� Conservative(cumulative balance day 1-7 of -136ml) vs Liberal fluid

management(+6992ml)� No mortality benefit, but more ventilator and ICU-free days in conservative group

� Goal-Directed Therapy� High percentage of patients with ARDS present with septic shock� Early goal-directed therapy significant decreased mortality

NEJM 2006;354:2564-2575

NEJM 2001;345:1368-1377

Outline

� History and Terminology � Introduction of ECMO(ECLS)� Severe Acute Respiratory Failure (ALI or ARDS)� ECLS for ARDS � Evidence Based Medicine� Local Experience

Adult ECLS

� 1972, ECMO �������respiratory failure� 1975� 1st multicenter, prospective, randomized trial� � NIH (National Institutes of Health) �� ECMO in severe ARF

JAMA 1979

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� 48 � ���� � � � � � �� 42 � ���� � -� � –ECMO+ � � � � ���90 � �� � � � � � � � �� ! " # $ >90%� % & study ' ( ) * + , ) ECMO - . / 0 1

JAMA 1979

WHY ?

WHY?

� Lack of prior ECMO experience� Uncontrolled bleeding( average 2.5L/day), massive

transfusion may contributed to lung injury� Predominance of influenza pneumonia� % 2 & study 3 �4 5 ��ECMO for severe

ARF >10 6 1� 7 8 9 ……………………………………………..

Neonatal ECLS

� Dr. Robert Barlett Team� 1982 6 : ; ������������������45�����������

� :� � � >50%� � � � � � � � � � >90%� 1985 6 : ; RCT,������������������715��������

���� � 18 � � � � � , � � 80%Surgery 1982;92:425-433

Pediatric 1985;76:479-487

1990��� Case Series

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Selection Criteria� Indication� Transpulmonary shunt >30% (PaO2/FiO2ratio <100 or alveolar-arterial oxygen gradient (A-

aDO2)>500)� Compliance<0.5 mL/cm water/kg� Mechanical ventilation <5 days� Age younger than 60 years of age

� Contraindication� Age older than 60 years� Ventilator days >5� Evidence of irreversible brain injury� Incurable disease� Immunosuppressive therapy� Septic shock.