This document summarizes a presentation by Dr. Eddy Fan on extracorporeal membrane oxygenation (ECMO) and lung protective ventilation strategies for acute respiratory distress syndrome (ARDS). The presentation discusses how ECMO can be used to facilitate lung rest and prevent ventilator-induced lung injury (VILI) in ARDS patients who cannot be safely ventilated with conventional lung protective strategies. It reviews evidence that ECMO combined with lower tidal volumes and plateau pressures may improve lung inflammation outcomes. However, optimal ventilation settings for ARDS patients on ECMO are still unknown. The presentation then describes the SOLVE ARDS study which aims to determine best practices for lung ventilation during ECMO through an international survey, systematic review,

1. ARDS 3x3 Debate
Tuesday, December 8, 2015
ECMO: You’re Doing It All
Wrong!
Or Are We? (CON)
Eddy Fan MD, PhD, FRCPC
Critical Care Medicine
Medical Director, Extracorporeal Life Support (ECLS) Program
Director, Critical Care Research
Mount Sinai Hospital and University Health Network
Assistant Professor of Medicine
Interdepartmental Division of Critical Care Medicine
Department of Medicine, University of Toronto

2. Disclosures/COI
• Disclosures
• ALung Technologies (travel/honoraria)
• Dräger (travel)
• Nihon Khoden (unrestricted research grant)

4. “We had arbitrarily chosen 5 cmH2O pressure to keep the lungs
inflated above FRC. We do not know at this time whether this
represents the optimal requirement or whether pressure is
desirable or even necessary for optimal performance….
This study was not undertaken to extend the safe period of apnea
during electroconvulsive therapy, bronchoscopy….Rather we feel
the concept of long-term (as opposed to short-term) apnea with
extracorporeal carbon dioxide removal can affect present practice
of mechanical pulmonary ventilation in especially difficult cases.”
Kolobow T et al., J Thorac Cardiovasc Surg 1978;75:261-266.

5. TREAT THE “BABY LUNG” GENTLY

6. 0
10
20
30
40
50
Mortality
Before
Discharge
Home
(Percent)
6 ml/kg 12 ml/kg
P=0.005High Stretch
(Control)
- VT: 11.8
- PPLAT: 32-34
- RR: 18
- VMIN: 13
- PEEP: 8
Low Stretch
(Intervention)
- VT: 6.2 mL/kg
- PPLAT: 25 cmH2O
- RR: 29
- VMIN: 13 L/min
- PEEP: 9 cmH2O
The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342:1301-1308.

7. Terragni PP et al. Am J Respir Crit Care Med 2007;175:160-166.

8. Hager DN et al., Am J Respir Crit Care Med 2005;172:1241-1245.
ECLS?

9. Needham DM et al., BMJ 2012;344:e2124.

10. ECMO/ECCO2R and Lung Rest – Limit VILI
• Subgroup of moderate/severe ARDS patients in which
maintaining modest physiologic goals with lung protective MV is
not possible
• Extracorporeal gas exchange may facilitate lung rest and prevent the
need for injurious MV
• Complete apnea to spontaneous breathing
THE BEST WAY TO TREAT THE “BABY
LUNG” GENTLY?

11. Terragni PP et al., Anesthesiology 2009;111:826-835.
• Reductions in ECCO2R group
• VT from 6.3 to 4.2 mL/kg PBW
• Pplat from 29.1 to 25.0 cmH2O
• ECCO2R normalized PaCO2
(50.4 mmHg) and pH (7.32)
despite lower VT
• After 72 hrs of ventilation and
ECCO2R
• Significant improvement in
morphological markers of lung
protection and pulmonary
cytokines
• No patient-related
complications observed

12. Bein T et al., Intensive Care Med 2013;39:847-856.

13. Pham T et al., Am J Respir Crit Care Med 2013;187:276-285.
Pplat on ECMO Day 1 ΔPplat (ECMO) ΔP on ECMO Day 1

14. Lung Rest Ventilation During ECMO/ECCO2R
• Appropriate MV settings for ARDS patients on ECMO or ECCO2R
are unknown
• Optimal tidal volume?
• Optimal PEEP?
• Various strategies to achieve lung rest have been described
• Effects on inflammatory markers/outcomes have not been compared
• Role of spontaneous ventilation/extubation?

15. The SOLVE ARDS Study
Program
Strategies for Optimal Lung Ventilation in ECMO for ARDS
International Survey: T Telesnicki, J Marhong, M Detsky, L Del Sorbo, E Fan
Systematic Review: J Marhong, L Munshi, M Destky, T Telesnicki, E Fan
Pilot Study: L Del Sorbo, A Goffi, F Facchin, M Meineri, E Goligher, M Cypel, S Keshavjee,
A Pesenti, A Slutsky, L Brochard, N Ferguson, E Fan

16. A Strategy of UltraProtective lung ventilation with
Extracorporeal CO2 Removal for New-Onset
moderate to seVere ARDS
The SUPERNOVA Trial

17. Questions?
eddy.fan@uhn.ca