Ventilator Management on ECMO

Ventilator Management on ECMO has been a debatable topic for many years.   There have been many approaches to managing the sick lung without ECMO support that still create a lot of debate.  But when you add in the complexities of the ECMO system and support processes it becomes even more difficult to find consensus on the best way to adjust ventilator settings.   A small percentage of ECMO Centers have begun actually extubating patients on ECMO.  Some centers manage the ventilator the same as if the patient were not on ECMO.  Some centers perform tracheostomy, some just leave an endotracheal tube in even for prolonged ECMO runs that may last for weeks or months.

A recent article found in Europe PubMed Central entitled International survey on the management of mechanical ventilation during extracorporeal membrane oxygenation in adults with severe respiratory failure. highlights the wide variety of thoughts and practices across the globe.

ELSO (Extracorporeal Life Support Organization) has long recommended “rest” ventilator settings while on ECMO. The ELSO H1N1 Specific Supplements to the ELSO General Guidelines during the H1N1 crisis was to:

  • keep plateau pressures under 25
  • adjust FiO2 to under 40%
  • allow SaO2 in the 70’s and 80’s on VV patients
  • keep hematocrit in normal range to aid with oxygen delivery
  • early tracheostomy
  • minimize sedation
  • perform frequent bronchoscope
  • consider HFOV at low settings (MAP of 12-14 cmH2O) to help with lung recruitment

 

The recommendations go on to suggest there is no benefit in attempting recruitment maneuvers until there is some sign of some native gas exchange and aeration on x-ray noted in lung fields.  In addition, they mention that some have reported surfactant, prone positioning, fluorocarbon lavage, and percussive ventilation to be beneficial in some patients.

I’m a fan of this approach.  I’m a believer in the concept of rest ventilator settings even in the face of complete and total whiteout of the lungs and then allowing TIME for the lungs to begin to recover before forcing recruitment procedures.  But there are a lot of smart clinicians out there that take other approaches and have good success as well.

How does your center manage the ventilator on ECMO patients?

 

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