Download Ventilation and Pulmonary Problems during VA-ECMO

Ventilation and Pulmonary
Problems during VA-ECMO
Dr Malaika Mendonca
Division Chief, Pediatric Cardiac Surgical Intensive Care
Director ECMO Program
Sheikh Khalifa Medical City
18 March 2016
Ventilation and Pulmonary Problems during VA-ECMO
Objectives:
• Outline current ventilation strategies
• Describe general difference in ventilatory
support between VV and VA ECMO
• Review pulmonary complications during VA
Support
• Present approach and solution for
complications
• Discuss future perspectives and research
Ventilation and Pulmonary Problems during VA-ECMO
Current ventilation strategies:
Reviews:
Ventilation and Pulmonary Problems during VA-ECMO
Prospective studies:
1. Extracorporeal Membrane Oxygenation for Severe
Acute Respiratory Distress Syndrome (EOLIA)
Ventilation and Pulmonary Problems during VA-ECMO
Prospective studies:
2. SOLVE Study:
=> Can we apply the same thoughts,
principles and strategies for VA ECMO?
Ventilation and Pulmonary Problems during VA-ECMO
Ventilation and Pulmonary Problems during VA-ECMO
VV-ECMO:
VA-ECMO:
• Circulation still in series
with native circulation
• Replaces all or part of
the lung function
• Circulation parallel with
native circulation
• Replaces all or part of
both:
Heart and lung function
Ventilation and Pulmonary Problems during VA-ECMO
Ventilation and Pulmonary Problems during VA-ECMO
VA ECMO: Goal to have own cardiac output
=> Allowing “lung rest “ or minimal ventilation in VA ECMO may
result in:
• Hypoxic blood for coronary perfusion -> Risk of myocardial
ischemia
• Hypoxic blood for cerebral perfusion -> Risk of cerebral ischemia
Ventilation and Pulmonary Problems during VA-ECMO
Ventilation and Pulmonary Problems during VA-ECMO
High PEEP:
• Decreased venous return -> Reduction to cardiac output
• Increase the Pulmonary vascular resistance -> Right Ventricle
overload and reduced Left Ventricular compliance
Ventilation and Pulmonary Problems during VA-ECMO
Ventilation and Pulmonary Problems during VA-ECMO
Anesthesiology 2013; 119:303-16
Ventilation and Pulmonary Problems during VA-ECMO
Adequate ventilation ensures:
• Sufficient myocardial and cerebral oxygenation
• Less risk of atelectasis
• Possibility of weaning VA ECMO
Adequate FiO2 in VA ECMO ensures:
• Sufficient myocardial and cerebral oxygenation
• May decrease PVR -> Reduced RV afterload
Ideal mode of ventilation for VA ECMO has not been
identified yet
Ventilation and Pulmonary Problems during VA-ECMO
VA ECMO indications are mainly for cardiac failure:
• Post bypass
• ECPR
• Sepsis
• Bridge to heart transplant
• Toxins
Pulmonary Problems during VA ECMO
Are they existing?
Ventilation and Pulmonary Problems during VA-ECMO
Case 1: congenital heart disease - low cardiac output syndrome
after surgery - VA ECMO
Decision to start VA ECMO
What happened?
14h later
Ventilation and Pulmonary Problems during VA-ECMO
Case 1: congenital heart disease - low cardiac output syndrome
after surgery - VA ECMO
Left sided drain insertion
48 h ECMO decannulation and clearer lung
fields
Left sided hematothorax - bleeding common complication in VA
ECMO
Ventilation and Pulmonary Problems during VA-ECMO
Case 2: congenital heart disease - low cardiac output syndrome
after surgery - VA ECMO
Day 1 of VA ECMO
Day 7 of VA ECMO
Ventilation and Pulmonary Problems during VA-ECMO
Case 2: congenital heart disease - low cardiac output syndrome
after surgery - VA ECMO
Bronchoscopy- Obstruction of left main
Bronchus
3h after Bronchoscopy done
Ventilation and Pulmonary Problems during VA-ECMO
Case 3: congenital heart disease - low cardiac output syndrome
after surgery - VA ECMO
ECMO day 1:
Congenital heart disease
ECMO day 6:
Klebsiella Pneumonia isolated from ETT
Ventilation and Pulmonary Problems during VA-ECMO
Case 3: congenital heart disease - low cardiac output syndrome
after surgery - VA ECMO
Pneumonia treatment:
• Antibiotic coverage
• Chest physiotherapy and nebulization
• Lung protective ventilation with caution for coronary perfusion
VAV ECMO:
One venous drainage
Two returns
Hybrid approaches such as VAV ECMO can be considered
Ventilation and Pulmonary Problems during VA-ECMO
Case 4: congenital heart disease - low cardiac output syndrome
after surgery - VA ECMO
ABG :
7.34, PaO2: 247, Co2: 37, BE -2,
VBG : Sat 73%
Post Oxy: PaO2: 360, Co2 : 35
HB 98
ECMO initiation intraoperative
Ventilation and Pulmonary Problems during VA-ECMO
Case 4: congenital heart disease - low cardiac output syndrome
after surgery - VA ECMO
What is the problem?
Sat still 100 %
Do we need to intervene?
 Blood from ETT
Differential :
• Bleeding
• Pulmonary edema
6 h after admission
Ventilation and Pulmonary Problems during VA-ECMO
Case 4: congenital heart disease - low cardiac output syndrome
after surgery - VA ECMO
 No pulsatile flow because of no
own contractility
Venous return from Thebesian veins and bronchial veins
into LEFT atrium or ventricle leads to overdistention
Ventilation and Pulmonary Problems during VA-ECMO
That results in:
 Risk of stagnation and thrombus in left ventricle
 Increased LVED and overdistention will impair coronary perfusion
 Increased LVED and overdistention -> dilatation and regurgitation ->
Pulmonary edema
What now?
Left sided venting/drain
Ventilation and Pulmonary Problems during VA-ECMO
Case 4: Congenital heart disease - low cardiac output syndrome
after surgery - VA ECMO
Left Ventricular venting inserted
5 days after L Venting
Ventilation and Pulmonary Problems during VA-ECMO
Summary for ventilation on VA ECMO:
• Optimal ventilation strategies for VA ECMO are not
established and require further research
• “Rest the Lung”- strategy from VV ECMO can not be
applied automatically
• Amount of PEEP, higher FiO2 and adequate minute
ventilation is an important factor for coronary and
cerebral oxygenation
• Chest Physiotherapy and Nebulization may be
beneficial and should be used on individual case
basis
Ventilation and Pulmonary Problems during VA-ECMO
Summary for pulmonary problems:
Pulmonary problems occur during VA ECMO:
• External compression/bleeding
• Atelectasis
• Plastic bronchiolitis cast
• VAP/ Pneumonia
• Pulmonary edema
=> Require identification of the problem and adequate
treatment
=> Untreated may make the weaning process
impossible
Ventilation and Pulmonary Problems during VA-ECMO
One Unit: Heart and Lung
Ventilation and Pulmonary Problems during VA-ECMO