Does ECMO Actually Work? Jeffrey DellaVolpe, MD San Antonio Advanced Lung Symposium December 7, 2019 1 2019 SAN ANTONIO ADVANCED LUNG SYMPOSIUM Does ECMO Actually Work? Jeffrey DellaVolpe Director, Methodist ECMO Program Medical Director, Cardiovascular ICU 2019 SAN ANTONIO ADVANCED LUNG SYMPOSIUM 2019 SAN ANTONIO ADVANCED LUNG SYMPOSIUM What is the purpose of ECMO? 2019 SAN ANTONIO ADVANCED LUNG SYMPOSIUM Does ECMO actually work? 1972 2019 SAN ANTONIO ADVANCED LUNG SYMPOSIUM Does ECMO actually work? No! 10% survival in both groups! 2019 SAN ANTONIO ADVANCED LUNG SYMPOSIUM What went wrong? 10 days of mechanical ventilation prior to ECMO! High vent pressures/FiO2 in both groups 2L/day of bleeding & 2.5L/day transfusion requirement! Irreversible lung fibrosis at autopsy 1 2 3 4 5 6
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Does ECMO Actually Work?Jeffrey DellaVolpe, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019 1
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Does ECMO Actually Work?Jeffrey DellaVolpe
Director, Methodist ECMO Program
Medical Director, Cardiovascular ICU
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
What is the purpose of ECMO?
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Does ECMO actually work?
1972
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Does ECMO actually work?
No!
10% survival in both groups!
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
What went wrong?
10 days of mechanical ventilation prior to ECMO!
High vent pressures/FiO2 in both groups
2L/day of bleeding & 2.5L/day transfusion requirement!
Irreversible lung fibrosis at autopsy
1 2
3 4
5 6
Does ECMO Actually Work?Jeffrey DellaVolpe, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019 2
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
ECMO Trials
• Zapol. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA 1979
• Gattinoni. Low‐Frequency Positive‐Pressure Ventilation With Extracorporeal CO2 Removal in Severe Acute Respiratory Failure. JAMA 1986
• Morris. Randomized clinical trial of pressure‐controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med 1994
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
ECMO over the next 20 years….
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
ECMO over the next 20 years….
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
ECMO Trials
• Zapol. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA 1979
• Gattinoni. Low‐Frequency Positive‐Pressure Ventilation With Extracorporeal CO2 Removal in Severe Acute Respiratory Failure. JAMA 1986
•Morris. Randomized clinical trial of pressure‐controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med 1994
• Peek. Efficacy and economic assessment of conventional ventilatorysupport versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomisedcontrolled trial. Lancet 2009
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
63% v. 47% survival at 6 months without disability
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Also happening in 2009…
7 8
9 10
11 12
Does ECMO Actually Work?Jeffrey DellaVolpe, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019 3
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
201 influenza patients68 supported by ECMO
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
2009: the debate intensifies…
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
2009: the debate intensifies…
• Large, pragamaticstudy
• 63% v. 47% survival
• Cost effective
• 24% of patients transferred to an ECMO center did not receive ECMO
• Higher tidal volumes at non-ECMO centers
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Protocolized ECMO delivery
Protocolized mechanicalventilation
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
EOLIA results
Mortality 35% v 46%
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
As opposed to 2009, no controversies in 2018…
13 14
15 16
17 18
Does ECMO Actually Work?Jeffrey DellaVolpe, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019 4
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
EOLIA results – not so simple…
Mortality 35% v 46% 28% crossover
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
EOLIA results – not so simple…
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Are we asking the right question?
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Periphery
Pressure
Hydrostatic pressure
Edema
Interstitium
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Asking the right question: what are we treating?
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Asking the right question: what are we treating?
19 20
21 22
23 24
Does ECMO Actually Work?Jeffrey DellaVolpe, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019 5
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Asking the right question: should severity be the reason for choosing ECMO?
P:F ratio
Oxygenation index
Refractory hypercapnea
Murray score
PIPER score
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Asking the right question: should severity be the reason for choosing ECMO?
28% crossover
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Does ECMO actually work?
Improper use of technology?
No diagnosis used in selection
Severity necessitated ECMO in all trials
Assumption that ARDS was reason we needed ECMO
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Does ECMO actually work?
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Is ECMO on the decline?
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Is ECMO on the decline?
25 26
27 28
29 30
Does ECMO Actually Work?Jeffrey DellaVolpe, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019 6
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Maybe it should be?
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Post cardiotomy shock
“24 studies, 1926 patients, overall survival rate to discharge of 30.8%”
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Are we asking the right question?
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Are we asking the right question?
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Cardiogenic shock
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
PERCUTANEOUS
VASOACTIVEDrugs
VA ECMO
MEDICAL Management
IABP Tandem Heart
CentrimagLVAD
Heart Ware
TAH
SURGICAL
HM IIIHeartmateII
CirculiteLVAD
Impella
ECMO as spectrum of mechanical circulatory
support
31 32
33 34
35 36
Does ECMO Actually Work?Jeffrey DellaVolpe, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019 7
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Amount of vasopressor support needed
Mortality
Mortality and vasopressor requirement in cardiogenic shock
40%
20%
60%
80%
100%
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
ECMO for ventilation support
Mechanical ventilation
Driving pressure
Tidal volumes
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
CO2 clearance in ECMO
Gas
Blood
pO2 = 713
PaO2 = 40
pCO2 = 0
PaCO2 = 45
O2
BLOOD FLOW
SvO2
70%SaO2
100%
CO2
PaCO2
45PaCO2
<5
Bottom line:While oxygen increase by ECMO circuit is limited to 30%, CO2 can be decreased by almost 100%!
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
New patient populations for ECMO?
ECMO
Mechanical ventilation
Driving pressure
Tidal volumes
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Asthma
Unable to ventilateUnable to oxygenateObstruction with HD instability
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Failure to intubate?
37 38
39 40
41 42
Does ECMO Actually Work?Jeffrey DellaVolpe, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019 8
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Prevention of intubation?
Mechanical ventilation
Delirium/encephalopath
y
Progressive weakness/d
ebility
Vent dependence
Tracheostomy
Long term acute care
Frailty
Death
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Bridge to transplant
ECMO as BTT
Cannulationonce listed to
reduce vent/sedation
Rescue for patients on ECMO with
failure to wean
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Bridge to transplant
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Facilitate rehabilitation
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Extracorporeal CPR (ECPR)
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
ECPR
43 44
45 46
47 48
Does ECMO Actually Work?Jeffrey DellaVolpe, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019 9
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Prehospital identification for ECPR?
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Pulmonary Embolism
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M 2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Complex airway
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Complex airway
Elective ECMO use for induction anesthesia or surgery
ECMO use during airway obstruction due to life‐threatening massive hemoptysis
Emergency use for arrest w/ induction/
surgery
Deployment in the setting of life-threatening massive
hemoptysis
Elective ECMO use for induction or surgery
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
High risk electrophysiology procedures
49 50
51 52
53 54
Does ECMO Actually Work?Jeffrey DellaVolpe, MD
San Antonio Advanced Lung SymposiumDecember 7, 2019 10
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Post transplant
Primary graft dysfunction
Right heart failure
VasodilationIschemic/reperfusion injury
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Right heart failure post VAD
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Regionalized ECMO Care
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
What kind of tool is ECMO?
2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M 2 0 1 9 S A N A N T O N I O A D V A N C E D L U N G S Y M P O S I U M
Questions?
55 56
57 58
59 60
Related Documents
