ECMO/ECCO2R in Acute Respiratory Failure - reamedpitie.comreamedpitie.com/wp-content/uploads/2017/02/ECMO-ECCO2R-in-Accute... · Cardiology Institute [email protected] ECMO/ECCO

[email protected] www.paris-ecmo.orgCardiology Institute [email protected] www.paris-tcsecmo.orgCardiology Institute

ECMO/ECCO2R in Acute Respiratory Failure

Alain Combes, MD, PhDCardiology Institute, Hôpital Pitié-Salpêtrière, AP-HP

Inserm UMRS 1166, iCAN, Institute of Cardiometabolism and Nutrition

Sorbonne Pierre et Marie Curie University, Paris, [email protected]


Conflict of interest

• Principal Investigator: EOLIA trial• VV ECMO in ARDS• NCT01470703 • Sponsored by MAQUET, Getinge Group

• Received honoraria for lectures from • MAQUET, XENIOS, BAXTER


ECMO and ECCO2R…To decrease the intensity of MV?



LUNG SAFEEpidemiology of ARDS


Probability of hospital survival by driving

pressure


The evolving paradigm…• ARDSnet strategy might not protect against tidal hyperinflation

• When Pplat remains >28-30 cm H2O • Further decrease of Vt to reduce VILI

• From 6 to <2 ml/kg IBW• To decrease Pplat <25 cm H2O• To decrease ∆P < 12-14 cm H2O• With sufficient PEEP to prevent lung derecruitment

• Extracorporeal gas exchange for• Blood Oxygenation/Decarboxylation• Decrease the intensity of MV


What areECMO and ECCO2R?Same Technology

Different Objectives…


Membrane lung O2/CO2 transfer

O2 transferCO2 transfer

ECMO for oxygenation

ECCO2R for Decarboxylation


Influence of ECMO flow

Schmidt et al, Intensive Care Med, 2013

Adequate Oxygenation

Qecmo > 60% Qco

PaO2 mmHg

SaO2, %

PaCO2 mmHg


Influence of Sweep Gas Flow

Schmidt et al, Intensive Care Med, 2013

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ECMO and ECCO2R

ECMO• Large cannulas

• High extracorporeal flow• >5000 ml/min

• Large membrane oxygenator

• Full blood oxygenation

• Full blood decarboxylation

• High technicity, ECMO center

ECCO2R• Double lumen catheter• Low flow, respiratory dialysis

• 250-1000 ml/min

• Medium size oxygenator• No blood oxygenation• Partial blood

decarboxylation• Regular ICU


ECMO and ECCO2R…What is the Evidence?


Results of series of VV-ECMO in ARDS patients


The CESAR trial


• UK, 2001-2006

• ECMO provided only at the Glenfield Hospital, Leicester

• Entry criteria:

• Adult patients (18-65 years) • Severe, but potentially reversible ARDS• Murray score ≥3.0, or • Uncompensated hypercapnia: pH <7.20

• Primary outcome measure

• Death or severe disability 6 months





Time from randomization to death

Log rank p = 0.03








17 (25%)


Et al…


Et al…


Et al…


• The French REVA Registry collected data of patients hospitalized in ICUs

• For H1N1-associated ARDS

• Analysis of factors associated • With death among 123 patients who received ECMO

• Case-control study with • Matching on a propensity score to receive ECMO



Why early ECMO?


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MV >7 days before ECMO

P <0.005, log-rank


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Results ECCO2R seriesin ARDS patients


Morris AH, et al. Am J Respir Crit Care 1994;349:295−305.

Randomised clinical trial of pressure-controlled inverse ratio ventilation and ECCO2R for ARDS

Study design

• Randomised controlled clinical trial

• 40 patients with severe ARDS

• ECCO2R versus MV

– Low-flow veno-venous ECCOR2 device

Results

• No significant difference in survival at 30 days (p = 0.08):

– 42% in the MV group (n = 19)

– 33% in the ECCO2R patients (n = 21)

– All deaths occurred within 30 days of randomization

• Study stopped for futility

• >30% patients with severe haemorrhage


Techniques of the 2000’s…


Novalung, ILA, Pumpless AV shunt


Novalung, ILA pumpless AV shunt






Frequency of complications and adverse effects

Complication / side effect Patients (n)

Ischemia of lower limb after cannulation 9

Cannula thrombosis 4

Compartmental syndrome in a lower limb 4

Haematoma / aneurysm at cannulation site 2

Haemolysis 1

Intracerebral haemorrhage 1

Diffuse bleeding / shock syndrome during cannulation 1

All 22 (24.4%)

Limb ischemia

due to arterial

cannulation +

need for IV

norepinephrineOverall frequency

of complications

and side effects

was 24%


Hemodec DECAP



Individual and average (horizontal bar) respiratory variables

before and after initiating CO2 removal

VT (mL/kg PBW) Pplat (cm H2O) PEEP (cm H2O) PaO2 / FiO2)



Techniques of the 2010’s…


NOVALUNG


• iLA activve, Novalung, ILA membrane • 22 French double lumen cannula• Ten patients hypercapnic respiratory failure• Step 1:

• Sweep gas flow increased from 1 to 14 L/min• At constant blood flow

• Step 2: • Blood flow gradually increased at constant sweep gas flow

• At each step measurement of • Arterial blood gas AND • Membrane gas transfer



Hemolung, Alung Technologies


Feasibility and safety of low-flow extracorporeal carbon dioxide

removal to facilitate ultra-protective ventilation in patients with

moderate ARDS


Time course of CRS Time course of driving pressure

Feasibility and safety of low-flow extracorporeal carbon dioxide

removal to facilitate ultra-protective ventilation in patients with

moderate ARDS


PALP, MAQUET®


PrismaLung (Baxter)


Anesth Crit Care Pain Med 2014

Mean CO2 removal rates at FsO2 1

Preclinical study in 5 adult hypercapnic pigs to investigate the performance of thePrismaLung system with different flow rates (blood flow/ sweep gas flow)


More to come…


A new paradigm…


Mild ARDS Severe ARDSModerate ARDS

Incre

asin

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Low Tidal Volume Ventilation

Higher PEEP

Low-Moderate PEEP

Prone Positioning

NIV

Neuromuscular Blockade

Inhaled NO

ECCO2R

ECMO

HFOV

The ARDS Definition Taskforce. JAMA 2012;307:2526-2533.


“In God we (may) trust; all others

must bring data…”W. Edwards Deming

(1900-1993)


We need EOLIA… A new trial of

ECMO for severe pneumonia/ARDS241 patients randomized so far…

YESWECAN

YESWECAN


A Strategy of UltraProtective lung ventilation

With Extracorporeal CO2 Removal for

New-Onset moderate to seVere ARDS

The SUPERNOVA trial


Conclusion

• ECMO/ECCO2R: Potential for use in moderate to severe ARDS patients

• To allow further reduction of Vt/Pplat/∆P, to limit VILI…

• ExtraCorporeal CO2 Removal

• “Respiratory dialysis” for moderate ARDS

• VV-ECMO

• For refractory hypoxemia

• For severe ARDS?

• Before large diffusion, (re)test the concept in large randomized clinical trials…


ECMO/ECCO2R in Acute Respiratory Failure - reamedpitie.comreamedpitie.com/wp-content/uploads/2017/02/ECMO-ECCO2R-in-Accute... · Cardiology Institute [email protected] ECMO/ECCO

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