August 18, 2024 • 38 mins
Dr. Alain Combes has is a professor of intensive care medicine at Sorbonne Université in Paris. Dr. Combes’ research focuses on the care of critically ill cardiac patients, mechanical circulatory […]
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(00:00):
So it is my delight today to introduce
our speaker for today. So Doctor. Combs is
here speaking to us from France.
He's a person who probably needs no introduction
at all. He's been instrumental
in clinical trials and research pertaining to ECMO
and mechanical ventilation
in patients on ECMO. I've been reading his
(00:20):
work for
many, many years, and I'm absolutely so grateful
that he could be here to share with
us.
I think of note, it's it's about 9
o'clock on a Friday night, I think, where
you are. So I'm even more grateful that
you're you're willing to be here with us
today.
And so with that, I will, go ahead
and hand it over to you, doctor Combs.
Okay. Thank you. Actually, it's it's only 7
(00:41):
because we are still in, in the winter
times. We will,
switch to the, summertime
clock, the next,
next Sunday.
Okay. So thank you very much for inviting
me.
I will discuss with you in the next,
30, 35 minutes, the, different ways of mechanically
machining the, patients on adenovineous ECMO, and,
(01:02):
we'll have some time for discussion at the
end.
So this is first my, disclosures,
regarding this talk.
So first,
why do we use ECMO,
in, severe
ARDS patients? Well, there's a few patients. I
would say
no more than 5 to 10% of all
(01:22):
ARDS patients,
who have the most severe forms will need
ECMO because of refractory
hypoxemia
or in patients in wound mechanical ventilation becomes
very dangerous.
We have seen those patients, of course,
during the COVID 19 pandemic,
mostly,
severely,
approximate patients here,
(01:45):
with diffuse consolidations
in both lungs. But once again, ECMO
in most of the patients who have severe
ARDS will be used to decrease the intensity,
of mechanical ventilation,
with the idea to reduce ventilator induced lung
injury.
This is something we had summarized in a
(02:05):
review paper in Csaba a couple years ago
with Dan Brody and Arslutsky.
So beyond the fact that, a machine is
a complete
machine
here used mostly for
gas exchange, complete,
extra extra couple lung, providing,
c two removal and,
(02:27):
blood oxygenation.
It allows also physicians
to
minimize,
lung stress and strain and all the components
of what has been called,
injury,
which is a mix of a volume trauma,
trauma, trauma,
and bio trauma, which is the production of
(02:49):
pro inflammatory cytokines,
within the the lungs, which may actually spill
over into,
the blood circulation and have deleterious
effects
in,
distant organs.
And, well, to minimize lung stress, right, obviously,
we're going to decrease all the parameters,
on the vent to decrease the tidal volume,
(03:11):
the pressures,
the plateau pressure,
the
driving pressure, which is the plateau minus the
p,
and also, the respiratory
rate.
There is another point, which is a very
important here if we believe
that
this concept
(03:31):
is valid.
There's clearly a need to, rapidly decrease the
intensity of mechanical ventilation in these patients.
There's a lot of papers,
analysis,
which have obviously
demonstrated,
that the number of days,
of,
invasive mechanical ventilation,
(03:51):
until,
the time where the patient receive
is, independently
associated with mortality. This is something we,
had shown, some years ago,
in a,
multicenter service in France. And in that series
was,
close to 150 patients included here.
There was an increase in mortality by 7
(04:14):
percent per additional
day
of mechanical ventilation awaiting ECMO.
So this is a very important point here,
and we when we broke down the population
into 3 groups, those who got very early
ECMO within the first two days between 3
and 10 days and after 10 days.
As you can see here there was also
a clear separation here of the survival rate
(04:35):
of those patients
advocating for very early use of ECMO and
obviously
in that series of patients, we also used
a super protective
mechanical ventilation in
our ECMO patients. So, there was
a steep decrease in the driving to the
title volume, plateau pressure, and respiratory
(04:56):
also
between just before and after
ECMO when it is it was initiated
and,
we all obviously gathered also a lot of
data during the COVID 19 pandemic probably more
patients treated within a Venice ECMO
induced, 2 to 3 years than ever before.
And, this is, one of the first people
(05:19):
we published. This was the experience of the
Greater Paris.
It was the first wave just 4 years
ago now,
in late March until
the end of May of 2020.
And,
during that time, we, treated,
in, the Greater Paris more than 300 patients
on.
And once again, when looking
(05:41):
at the delay,
the time between
and ECMO,
this time was
here,
the first two days,
between intubation and ECMO, which were clearly a
series of data. It was not that much
difference between 3 and 6 and over 6,
but clearly,
this is,
obvious here that the sooner the better, if
(06:02):
your objective is to decrease intensity of mechanical
ventilation. So
this is the main objective. So to do
this,
I've talked to you about all the parameters
which might impact, Vili.
And, when looking at the recent literature,
obviously, the the driving pressure of the people
at minus the peep is,
(06:23):
one of the target, we should focus on,
in these patients.
And probably,
together,
I was a slight increase in peep,
to prevent,
land or recruitment. I will talk to you
about in a minute,
but the driving pressure, we have a lot
of data with this beautiful
(06:45):
New England paper by, Marcelo Amado showing that,
independently
of the peep of the plateau of the
title, it was clear the driving pressure,
which was
clearly exceeded with a mortality
and was the independent factor associated with mortality
with
driving pressure
(07:06):
above 50,
being exceeded with
an increase an exponential
increase in mortality. So
once again, if we believe that this should
be a target,
the target of the driving
on ECMO,
should clearly be should clearly be below 15,
might be below 10 as well. This is
(07:27):
something we need to probably evaluate,
in the future.
Another study we did here, was an international
prospective observational study of more than 300 patients
on Venus.
They were all treated in experience centers. And
once again, if you are looking here at
the driving,
a pre ECMO was close to 20, and,
(07:48):
it was
clearly below 15 in most patients
on day 1,
and, the days
after,
once ECMO
was initiated.
These are all data now. These are data
from, h one and one patients we treated
(08:09):
in France,
more than 10 years ago now.
And, in that series of patients,
it was just the beginning in France at
that time of the diffusion of the technique.
And,
well,
there was some centers in which, there was
no modification of the sent parameters,
especially,
the driving and the peep
(08:31):
and we have always the,
different
people
and driving per
in survivors,
which is non survivors. It was clear clear
here, difference between the two groups,
with
a clear benefit of decreasing
most of these, partners,
as you can see on the right part
(08:51):
of panel here.
The median value of the p platform
survivors was clearly below 15 in these series
of patients.
Well, this is another one published a couple
years later.
It's, an international
database analysis
showing again that the driving pressure,
(09:13):
was a seated with
better prognosis. And this is the latest,
published,
in intensive care medicine a couple of months
ago.
This is based on the very large registry
here.
And
this is a problem in the registry.
It's only,
(09:33):
the peak pressure, not the p plat, which
is,
in the database. So they were not, it
was not possible to evolve with the the
lateral,
pressure, was only the peak. So it was
the dynamic driving, which was evaluated in that
paper, but,
this
dynamic pressure was again associated with a difference
(09:55):
in mortality
for those patients who got a lower dynamic
driving pressure.
It was in survivors was 11 versus 20,
in non survivors. So,
and the mortality difference was highly significant here.
So this is a very important point here.
1st,
decrease the title
(10:16):
and target a lower,
driving pressure,
when the PIP plat or the inspiratory pressure
has been decreased.
PIP setting. PIP setting is always complicated in
the audience patients,
and,
there's something also which
appeared clearly now in recent years, is the
(10:36):
fact that in up to 1 or maybe
up to 40 to 50 percent of the
patient, there might be,
a phenomenon which is called airway,
opening pressure. And,
this,
point,
where the airway is either opening or or
closes
can be detected by a low flow in
(10:58):
flash inflation pressure time curve,
to detect this,
way of the opening pressure, which is usually
between 8
and up to 12,
14 centimeters of water. And, clearly, if this
is the case,
the patient should receive a peep should be
at least, 2 centimeters above, this, airway
(11:21):
opting,
pressure. And this is clearly the first step,
and,
there is a risk at decreasing the tidal
volume, the pressures, the driving pressure of the
plateau
is land recruitment.
And this is, also a reason why there
may be a higher of this,
closing pressure opening pressure in the patients on,
(11:43):
venous
ECMO.
What is the be the best peep,
in, venous ECMO patients?
Most of the centers
now target PEEP between, let's say, 8 up
to 15,
maybe a a bit more in some patients.
(12:04):
And,
this is something we had evaluated,
in,
3,
international
centers, 2 in Australia, in our centers in
Paris.
And,
in that
retrospective
database and then disease, we also showed that,
there was an impact of the peep setting
(12:24):
during the 1st days of, veno venous ECMO
with higher peeps, let's say, between
12 and 14 being exceeded with
better prognosis as compared to those patients who
will receive lower piece between 10 and 12.
And,
the mean peep,
from day 1 to day 3
(12:45):
was clearly here,
seated with
mortality
in the ICU.
This has been
a high interest
from our group for years now, and, we
have applied
EIT, electric impedance tomography,
to monitor,
people in these patients. This is
(13:07):
a clinical review we just published in the
blue journal about,
EIT in ERDS,
which
has some limitations, of course, because
it's evolving on only one slice of, of
the lung with the the the the the
little delta, which is around the the chest
in in those patients. But
it can be applied,
(13:28):
also, and this is the first time we,
when the the paper was published, it was
applied to patients. And, in that series, we
showed that it was possible,
to using when using a PIP trial from,
decreasing from 20 to
zip to 0 of peep,
(13:48):
by increments of 5 centers of water,
to evaluate
with EIT,
the regions of the lung,
in which there were over distension
or,
a. And
it's possible with,
creating curves from, those
EIT analysis to determine what is the best
(14:09):
PEEP,
which is the compromise between
collapse and overdistension.
So,
and there's obviously,
differences between patients. One size does not fit
all or again for, venous,
ECMO patients. And in that study, we showed
that the the best peak was very different
from patient to patient
(14:30):
on the
top of
the slide here with patient with the in
whom the optimal PIP was 15. Some is
more.
It was only 10 in the
patient at the bottom.
And
this, try should
that PIP 0, zip, and very high PIP
(14:53):
were never selected.
Very high PIP were clearly exceeded with over
distance while
lower peeps,
especially Zip,
was seated with,
at elective and lung collapse. But there were
some patients in who it was 5,
10, 16,
Sue.
In the first approach, you might select to
(15:13):
peep, let's say, between 12
14, 15.
But once again,
this might be adapted,
and, I will talk through about a bit
about monetary,
at the end of
of the talk.
The respiratory rate, well, also, clear data,
gathered during the lung safe
(15:34):
epidemiologic analysis
for large,
surveys of patients,
ARDS patients on mechanical ventilation, and was the
first time that the respiratory rate was disease
mortality.
And, the difference is actually, quite significant here.
Mortality increased by 3% for additional breaths per
minute.
This is probably a threshold, let's say, between
(15:56):
25,
26, 27 above which this becomes highly significant.
But setting up, the respiratory to go 3
or at 35,
is clearly, associated with higher mortality. And this
holds true also for patients on,
veno venous ECMO.
And these,
some indirect data, this is a very,
(16:19):
smart animal
experiment
in peaks,
which were ventilated
using the so called the ARIA strategy,
with the same level of peak, which was
around 10.
And the two groups differed only by one
factor, which was the respiratory rate. In control,
peaks, the rate was 30 per minute,
(16:42):
and, they used ECCOIR,
to reach
14,
breaths per minute
while controlling,
c o two clearance
by
the
vent. But since the minute ventilation was decreased
on the vent,
the extra
(17:04):
c o two was cleared in,
experimental animals with the ECCO device.
And, in that very short
study period of time was, the study experiment
was
just a couple of hours,
and they measured,
the pro inflammatory cytokines boost in the blood
(17:24):
and in the BIL fluid. And it would
last,
actually, last pro inflammatory cytokines in blood and
BAL,
in, the
pigs,
in which the respiratory was decreased to 14.
So
once again, confirming what is
being called biotrauma here,
in,
which is clearly a component of a ventilator
(17:46):
induced like the injury.
The latest,
which may also become a target for mechanical
ventilation
boost,
in the RDS patient and, of course, in
patients,
on venous
ECMO is the mechanical
power,
which is the global energy, which is transferred,
(18:08):
to the lungs, and, the alveoli
by the vent.
This partner and to raise the tidal volume,
the driving pressure,
the fluid PEEP, which is a static component,
of this energy and the respiratory agent of
those parameters.
It's once again probably the driving pressure, which
has the strongest
(18:30):
impact, on,
the wood energy
with the respiratory rate being the the second,
in terms of the importance here. The formula
is quite complicated, but there's a
simplified formula which might be
calculated by the vent itself at the bedside.
And,
(18:50):
there's some data also suggesting that there also
may be a threshold for the mechanical power.
Here is an adjusted. You may adjust that
to,
the specific elastance of the respiratory system,
for example, or the predictive body weight of
the patient. And
in that study here, which is a reanalysis
(19:12):
of large,
randomized studies,
it seemed that there was a threshold
around 17 18 of,
joules per minute to see a unit of
the energy of the mechanical power here, above
which,
there was a significant
increase
in mortality.
And, once again, back to our lifeguard,
(19:33):
who works here,
350
patient of ECMO.
And when looking back at, the VANS setting
just before ECMO and, what was
applied to the patient on day 1,
the draw the mechanical power, as you can
see, he was clearly highly elevated above 20,
so above the
so called threshold of,
(19:55):
a silo with higher mortality. And, obviously, by
decreasing the title to very low levels, same
for the driving pressure, the respiratory,
the mechanical power, becomes very low, less for
fuller than 10 around 5
joules per minute once echo, has been
initiated.
So the next step
(20:15):
might be moving to apneaic ventilation
here
to have,
0 of driving,
just some,
CPAP or,
PEEP
being applied,
to, the patient. And for now, there's no
convincing,
data in humans, but, there's been some, animal
(20:37):
data again
in in a model of of peak here,
showing that this near apnea ventilation
was
a very low,
respiratory rate, very low
tidal volume
was the condition which was associated with,
less, damage
(20:58):
damage,
to, to the lungs.
So this is the next,
area for research now, and we might discuss
that, of course, at the end of,
in this lecture.
Okay.
ECMO also,
since it's
a loose gas exchange from the, trap or
a log,
(21:19):
a membrane log, it will lose to decrease,
the ventilator FiO2,
which may be associated with less toxicity from
high level of oxygen and also,
preventing a trojanation and select disease, which may
occur, if there is
very high FiO2
used on the mechanical ventilators.
(21:39):
So this is something also which is
clearly
demonstrated
and the objective is
(22:03):
It might be decreased over time when the
patient improves, but, the objective is first to
decrease the FIO 2 on the vent,
leaving the f m o two on the
mamrilang,
at 100% at the beginning
of,
the,
f Moran.
There is another question, which is, still a
(22:24):
matter of,
debate.
Should we let the patient risk, or should
we
use deep sedation or pyrolysis here,
to,
completely abolish,
spontaneous ventilation?
Well, when looking back to the literature,
there's some papers showing that it may be
(22:45):
good to have
some, spontaneous ventilation to preserve,
respiratory,
muscle,
especially the diaphragm function, and we might be
also associated with a better VAQ match and
regional ventilation.
And
well, this is something we try to apply
to our patient,
(23:05):
using the APRV mode, which is a form
of BiPAP in which,
there is no synchronization of the respiratory
force
of the patient,
and the 2 levels of pressures, which are
generated
by the ventilator.
So it prevents,
the,
very high,
swings of, transferratory
(23:27):
pressure, which is
sometimes encounters in patients who have the regular
forms of BiPAP in which every spontaneous support
of the patient
leads to
an opening of the valves and
respiratory movement here. The patient can breathe on
top of the two levels of
pressures, but once again, there's no synchronization and
(23:48):
maybe less risks
of
transparent pressure swings here,
in, the patient. So this is the
ventilatory mode we,
applied,
to our,
ECMO
patients.
Setting up the peep once again,
let's say, between 12 and 15, the beginning
(24:09):
and targeting a driving,
between 10 12,
maybe for so less than 15 here,
and,
monitoring the respiratory rate. If the patient is,
having
a deep
respiratory fort and strong respiratory drive, this might
be an indicator of the need for,
(24:32):
a paralyzing agents or deep sedation at least
for the 1st days. And this is something
that we also should have observed during the
COVID, those patient at the very strong,
respiratory drive with a very high,
respiratory rate and also a very
deep and strong respiratory reports, which might have
(24:52):
been associated with,
VD. So,
obviously, if it's the case, the patient might
be paralyzed initially. But once it's possible, this,
APRV mode,
is probably
one good solution, although we need
more studies also to prove that.
(25:13):
The last point on APRV was originally described
by,
releases of pressures. Most of the time, the
patient was on the high level of pressure.
We do not use APRV that way. We
use APRV with a classical,
1 to 2,
inspiratory to, expiratory
ratio.
(25:33):
Well,
and what actually we did in the OLEA,
OLEA was launched, more than 10 years ago
now, and we included the patients,
with, 3 entry criteria, the below 50 for
more than 3 hours or below 80 for
more than 6. And there was also a
search criteria of respiratory,
(25:53):
ACDU disease with the PACU to over 60
for more than 6 hours.
And most of these patients had a very
low,
compliance
and,
needed,
also very high respiratory rate,
to,
reach these,
p c o two objectives. And
what we did in Neolia was
(26:15):
to use
a
coagulation and,
settings of the Maven event were either volumetric
control
with a people of a 10 and the
set to reach a p plat below 24
or,
the pressure control mode was mostly the APRB
mode with the same,
level of pressures. And, well, if you have
(26:35):
the same objective in terms of driving,
peep,
well,
at the end, you have just the same
type of volume, and, there was no,
also recommendation to decrease the respiratory
to 10:10 to 15 as it's the case
in the ELSO,
recommendations
here. It was a bit more liberal here
(26:56):
for the respiratory.
So, well,
showed that there was
a trend towards a benefit
in mortality with ECMO, and it was also
when looking at the secondary endpoints,
there was a benefit in each of those
secondary end points regarding the days
free of valve pressers, free of cardio,
(27:18):
of,
cardiac failure, dialysis, renal failure, and the prone
positioning and and nitric oxide.
This is here, well, what we did,
the title was at 6,
initially as expected for severe ARDS patients, and
it was decreased below 4. It was around,
3.5,
during, the 1st days of ECMO. Same for
(27:40):
the plateau, which was around 30. Initially, it
was decreased to to around 24.
While the PEEP,
was maintained,
virtually the same in both group, it was
around 11 to 12 in the 1st days
of ECMO. And, obviously, decreasing the
title than the plateau while maintaining the PEEP,
We ended up with a much lower driving
(28:01):
pressure. It was around 18,
at and,
it was decreased decreased to around 13,
once the patient was on.
Also, those patients on ECMO was possible to
decrease the PA CO 2 to increase the
oxygen saturation,
(28:21):
and to
increase the pH
as well
as expected with this type of machine center.
This is the primary endpoint here as you
can see,
the, was a trend, p value was 0.07
with,
mortality being, 35 in equipations and 46 in
controls.
(28:43):
We have also a key secondary,
which
was,
tests for echo patients. So that's the need
for a crossover,
in controls.
And this time, there was
a major difference significant difference between the two
groups.
As frequently
done now we also
use bias and stats
(29:03):
to
reanalyze
the results of Eovia and
with these statistical
methods, it was
concluded that the probability of ECMO saving lives
in ECMO patients was very high actually,
above
90% for most of the hypothesis
(29:24):
and this is the reason why Direct Angus
concluded from,
that reanalysis
that, well, clinicians and researchers should no longer
ask does ECMO work?
Because clearly, that question now appears to be
answered. Yes. ECMO works. Now we need to
know by how much will might work cost
and maybe to improve,
(29:44):
some,
management also. And the next question, which came
after Ionia,
was,
the proposition.
We had
some convincing
evidence from,
the ERDS literature of benefit of,
and
especially for those who had the most severe
forms.
And this is the
(30:05):
reason why we launched the product mostly,
pruning,
venous ECMO patients. This is obviously more complicated
than doing this
in, non ECMO patients, but it's feasible. It's
possible.
You need at least 6 p 6 people
to,
roll over a patient in the bed and
(30:26):
put the patient,
pruned,
and you need to protect also the patient
from pressure source. And this is here,
the face mask we use, to protect the
the skin and
the face of the patient.
So, well, once again, there was
(30:47):
an hypothesis here of combining, veno venocectal, which
in the showed that there was a trend
for
mortality benefit together with,
the
study
in
regular ARDS patients. And, well, we did the
study. It was mostly during the COVID 19
pandemic,
(31:07):
and,
the report was published in JAMA a couple
weeks ago.
And, well, the study was negative.
The primary endpoint
was,
the
successful winning of ECMO,
within the 1st 60 days after randomization, and,
actually, it was no difference, between,
patient were pruned and not pruned.
(31:29):
There was no difference also in mortality,
in that study,
which had included 170
patients. Well, once again, it's very specific year
of,
COVID 19 patients.
They represented
90%
of the,
included patients here,
And, well,
this form of ARDS was
(31:51):
not the classical form of ARDS and specifically
because
of the very prolonged acmoron we had, in
these patients, which was an average 3 to
4 weeks.
And in PRONEC, we did only 4 sets,
4 days
of PRONEC positioning
at the very beginning
of the ECMO run. So this might explain
(32:13):
why there was no
benefit here, and, there was no subgroup,
also in which, there was a trend towards
a benefit. So,
should we continue to prone patients?
Definitely, I don't know.
Personally, I believe that there might be some
patient who might benefit,
especially those who have the so called low
bar
(32:34):
ARDS,
those who have consolidation may be the dependent
partial origins of,
of the lungs. Those patients might benefit from
being pruned.
This might not be the case of patients
who had diffuse
confluent,
lesions,
as were was the case for most of
the, COVID 19 patients.
(32:56):
One of the last points,
was is monitoring, especially,
the initial monitoring of PEEP setting. This is
a one paper,
review people who published last year about that.
I've showed you some
pictures of, the EIT. If you have access
to that technique in your ICU,
during the 1st days of ECMO, this is
(33:18):
actually probably a very good one,
to
set up the best peep. It's not invasive.
It's
used at the bedside, graduation free,
and it's also dynamic
assessment of the of the lungs with direct
images
here provided by by by the machine.
(33:39):
But it's only one region. It's just a
cross section of,
one slice of of the lung and,
well, it's still time consuming,
and, the the machine is still
not available in our ICUs.
One of the best technique is,
the,
thoracic,
CT,
(34:00):
in which you might also use
a a PEEP trial here, but definitely here,
it's quite complicated to, get the patient to,
do is very sick patients and,
to to the, radiological,
lab to to have,
CT. And
the other technique which might be used is
the,
primary pressure guided with the,
(34:23):
the fragile
balloon and probe here, to, monitor
the transfer pressure.
This might not be actually
one good
solution,
although there's some,
artifacts also with this technique and
(34:43):
setting up the the the right
0 is is sometimes a bit cumbersome here
and
the the the the the the prove might
move, etcetera. So, there's some also drawbacks with
that, but it's probably,
the technique which is the the most simple
at the bedside.
Last,
well,
probably, it's better not to ventilate at all
(35:05):
patient to let them extubate it. I talked
to you about
the the ventilation, but another solution would be
to constantly extubate the patient.
This has been called AWAKE,
ECMO.
That's
worked in the literature, but it's well, when
looking, it's mostly for patients who have bridged,
(35:27):
to lung transplantation. The very few, ERD patients
were able to sustain
spontaneous spontaneous
bracing,
and getting extubated
on ECMO. There was a small
study
in a group
working in Rush University, which is very close
to Chicago,
during COVID 19, which, actually activate their patients
(35:50):
after 10,
15 days.
And the patient got an extra,
2 weeks of, ECMO awake,
and they got good results but it's
probably one of the only group in which
it was
reported here so
well it's probably for very severe ARDS
not very
easy
(36:12):
to have those patients completely
extubated.
So, to sum up,
ECMO,
allows you to markedly reducing
intensity of mechanical ventilation, and this is probably
the way, it improves the survival of the
patients.
In most cases, once again, the the patients
(36:32):
were dying of
hypoxemia,
very,
low
compliance, high elastance here in need of a
rare high precious
is much less frequent.
And,
this is clearly the paradigm here, which is
using
ECMO patients to reduce VV.
(36:52):
And the targets here, the title is usually
much lower than 4, and it's
the most severe forms. It's usually below 1
and sometimes,
almost virtual here,
with the driving, which should be for 4
less than 15. Our target is 10:12,
around 10, 12, now.
And,
if possible, also, it might be interesting to
(37:14):
decrease respiratory rate while PEEP
might be the best scenario is to adjust
PEEP to,
the need of each patient, but once again,
it's not that
easy at the bedside.
A simple,
P trial measuring
exchange
and,
(37:34):
the respiratory mechanics of the patient might help
without any other technique. And it's also very
easy to measure,
the airway opening pressure if it exists
to
to set up the peep just above that
we,
of the impression. Still many, many questions from
(37:54):
Amy.
Is it possible
to reach near apnea ventilation? This is something
we may test here in the future trial
in our unit.
Is it better, using volume,
assisted ventilation
pressure mode, something also which may be the
target of a future trial? And,
(38:16):
well,
group positioning
clearly remains,
a major issue because, once again, we tested
that
mostly in COVID 19 patients and probably does
not answer,
the question for the called more regular,
ARDS
patients.
Well,
(38:37):
with that, we'd like to thank you very
much for listening, and we may discuss,
now, for a couple minutes, the questions you
might have.
So it is my delight today to introduce
our speaker for today. So Doctor. Combs is
here speaking to us from France.
He's a person who probably needs no introduction
at all. He's been instrumental
in clinical trials and research pertaining to ECMO
and mechanical ventilation
in patients on ECMO. I've been reading his
(00:20):
work for
many, many years, and I'm absolutely so grateful
that he could be here to share with
us.
I think of note, it's it's about 9
o'clock on a Friday night, I think, where
you are. So I'm even more grateful that
you're you're willing to be here with us
today.
And so with that, I will, go ahead
and hand it over to you, doctor Combs.
Okay. Thank you. Actually, it's it's only 7
(00:41):
because we are still in, in the winter
times. We will,
switch to the, summertime
clock, the next,
next Sunday.
Okay. So thank you very much for inviting
me.
I will discuss with you in the next,
30, 35 minutes, the, different ways of mechanically
machining the, patients on adenovineous ECMO, and,
(01:02):
we'll have some time for discussion at the
end.
So this is first my, disclosures,
regarding this talk.
So first,
why do we use ECMO,
in, severe
ARDS patients? Well, there's a few patients. I
would say
no more than 5 to 10% of all
(01:22):
ARDS patients,
who have the most severe forms will need
ECMO because of refractory
hypoxemia
or in patients in wound mechanical ventilation becomes
very dangerous.
We have seen those patients, of course,
during the COVID 19 pandemic,
mostly,
severely,
approximate patients here,
(01:45):
with diffuse consolidations
in both lungs. But once again, ECMO
in most of the patients who have severe
ARDS will be used to decrease the intensity,
of mechanical ventilation,
with the idea to reduce ventilator induced lung
injury.
This is something we had summarized in a
(02:05):
review paper in Csaba a couple years ago
with Dan Brody and Arslutsky.
So beyond the fact that, a machine is
a complete
machine
here used mostly for
gas exchange, complete,
extra extra couple lung, providing,
c two removal and,
(02:27):
blood oxygenation.
It allows also physicians
to
minimize,
lung stress and strain and all the components
of what has been called,
injury,
which is a mix of a volume trauma,
trauma, trauma,
and bio trauma, which is the production of
(02:49):
pro inflammatory cytokines,
within the the lungs, which may actually spill
over into,
the blood circulation and have deleterious
effects
in,
distant organs.
And, well, to minimize lung stress, right, obviously,
we're going to decrease all the parameters,
on the vent to decrease the tidal volume,
(03:11):
the pressures,
the plateau pressure,
the
driving pressure, which is the plateau minus the
p,
and also, the respiratory
rate.
There is another point, which is a very
important here if we believe
that
this concept
(03:31):
is valid.
There's clearly a need to, rapidly decrease the
intensity of mechanical ventilation in these patients.
There's a lot of papers,
analysis,
which have obviously
demonstrated,
that the number of days,
of,
invasive mechanical ventilation,
(03:51):
until,
the time where the patient receive
is, independently
associated with mortality. This is something we,
had shown, some years ago,
in a,
multicenter service in France. And in that series
was,
close to 150 patients included here.
There was an increase in mortality by 7
(04:14):
percent per additional
day
of mechanical ventilation awaiting ECMO.
So this is a very important point here,
and we when we broke down the population
into 3 groups, those who got very early
ECMO within the first two days between 3
and 10 days and after 10 days.
As you can see here there was also
a clear separation here of the survival rate
(04:35):
of those patients
advocating for very early use of ECMO and
obviously
in that series of patients, we also used
a super protective
mechanical ventilation in
our ECMO patients. So, there was
a steep decrease in the driving to the
title volume, plateau pressure, and respiratory
(04:56):
also
between just before and after
ECMO when it is it was initiated
and,
we all obviously gathered also a lot of
data during the COVID 19 pandemic probably more
patients treated within a Venice ECMO
induced, 2 to 3 years than ever before.
And, this is, one of the first people
(05:19):
we published. This was the experience of the
Greater Paris.
It was the first wave just 4 years
ago now,
in late March until
the end of May of 2020.
And,
during that time, we, treated,
in, the Greater Paris more than 300 patients
on.
And once again, when looking
(05:41):
at the delay,
the time between
and ECMO,
this time was
here,
the first two days,
between intubation and ECMO, which were clearly a
series of data. It was not that much
difference between 3 and 6 and over 6,
but clearly,
this is,
obvious here that the sooner the better, if
(06:02):
your objective is to decrease intensity of mechanical
ventilation. So
this is the main objective. So to do
this,
I've talked to you about all the parameters
which might impact, Vili.
And, when looking at the recent literature,
obviously, the the driving pressure of the people
at minus the peep is,
(06:23):
one of the target, we should focus on,
in these patients.
And probably,
together,
I was a slight increase in peep,
to prevent,
land or recruitment. I will talk to you
about in a minute,
but the driving pressure, we have a lot
of data with this beautiful
(06:45):
New England paper by, Marcelo Amado showing that,
independently
of the peep of the plateau of the
title, it was clear the driving pressure,
which was
clearly exceeded with a mortality
and was the independent factor associated with mortality
with
driving pressure
(07:06):
above 50,
being exceeded with
an increase an exponential
increase in mortality. So
once again, if we believe that this should
be a target,
the target of the driving
on ECMO,
should clearly be should clearly be below 15,
might be below 10 as well. This is
(07:27):
something we need to probably evaluate,
in the future.
Another study we did here, was an international
prospective observational study of more than 300 patients
on Venus.
They were all treated in experience centers. And
once again, if you are looking here at
the driving,
a pre ECMO was close to 20, and,
(07:48):
it was
clearly below 15 in most patients
on day 1,
and, the days
after,
once ECMO
was initiated.
These are all data now. These are data
from, h one and one patients we treated
(08:09):
in France,
more than 10 years ago now.
And, in that series of patients,
it was just the beginning in France at
that time of the diffusion of the technique.
And,
well,
there was some centers in which, there was
no modification of the sent parameters,
especially,
the driving and the peep
(08:31):
and we have always the,
different
people
and driving per
in survivors,
which is non survivors. It was clear clear
here, difference between the two groups,
with
a clear benefit of decreasing
most of these, partners,
as you can see on the right part
(08:51):
of panel here.
The median value of the p platform
survivors was clearly below 15 in these series
of patients.
Well, this is another one published a couple
years later.
It's, an international
database analysis
showing again that the driving pressure,
(09:13):
was a seated with
better prognosis. And this is the latest,
published,
in intensive care medicine a couple of months
ago.
This is based on the very large registry
here.
And
this is a problem in the registry.
It's only,
(09:33):
the peak pressure, not the p plat, which
is,
in the database. So they were not, it
was not possible to evolve with the the
lateral,
pressure, was only the peak. So it was
the dynamic driving, which was evaluated in that
paper, but,
this
dynamic pressure was again associated with a difference
(09:55):
in mortality
for those patients who got a lower dynamic
driving pressure.
It was in survivors was 11 versus 20,
in non survivors. So,
and the mortality difference was highly significant here.
So this is a very important point here.
1st,
decrease the title
(10:16):
and target a lower,
driving pressure,
when the PIP plat or the inspiratory pressure
has been decreased.
PIP setting. PIP setting is always complicated in
the audience patients,
and,
there's something also which
appeared clearly now in recent years, is the
(10:36):
fact that in up to 1 or maybe
up to 40 to 50 percent of the
patient, there might be,
a phenomenon which is called airway,
opening pressure. And,
this,
point,
where the airway is either opening or or
closes
can be detected by a low flow in
(10:58):
flash inflation pressure time curve,
to detect this,
way of the opening pressure, which is usually
between 8
and up to 12,
14 centimeters of water. And, clearly, if this
is the case,
the patient should receive a peep should be
at least, 2 centimeters above, this, airway
(11:21):
opting,
pressure. And this is clearly the first step,
and,
there is a risk at decreasing the tidal
volume, the pressures, the driving pressure of the
plateau
is land recruitment.
And this is, also a reason why there
may be a higher of this,
closing pressure opening pressure in the patients on,
(11:43):
venous
ECMO.
What is the be the best peep,
in, venous ECMO patients?
Most of the centers
now target PEEP between, let's say, 8 up
to 15,
maybe a a bit more in some patients.
(12:04):
And,
this is something we had evaluated,
in,
3,
international
centers, 2 in Australia, in our centers in
Paris.
And,
in that
retrospective
database and then disease, we also showed that,
there was an impact of the peep setting
(12:24):
during the 1st days of, veno venous ECMO
with higher peeps, let's say, between
12 and 14 being exceeded with
better prognosis as compared to those patients who
will receive lower piece between 10 and 12.
And,
the mean peep,
from day 1 to day 3
(12:45):
was clearly here,
seated with
mortality
in the ICU.
This has been
a high interest
from our group for years now, and, we
have applied
EIT, electric impedance tomography,
to monitor,
people in these patients. This is
(13:07):
a clinical review we just published in the
blue journal about,
EIT in ERDS,
which
has some limitations, of course, because
it's evolving on only one slice of, of
the lung with the the the the the
little delta, which is around the the chest
in in those patients. But
it can be applied,
(13:28):
also, and this is the first time we,
when the the paper was published, it was
applied to patients. And, in that series, we
showed that it was possible,
to using when using a PIP trial from,
decreasing from 20 to
zip to 0 of peep,
(13:48):
by increments of 5 centers of water,
to evaluate
with EIT,
the regions of the lung,
in which there were over distension
or,
a. And
it's possible with,
creating curves from, those
EIT analysis to determine what is the best
(14:09):
PEEP,
which is the compromise between
collapse and overdistension.
So,
and there's obviously,
differences between patients. One size does not fit
all or again for, venous,
ECMO patients. And in that study, we showed
that the the best peak was very different
from patient to patient
(14:30):
on the
top of
the slide here with patient with the in
whom the optimal PIP was 15. Some is
more.
It was only 10 in the
patient at the bottom.
And
this, try should
that PIP 0, zip, and very high PIP
(14:53):
were never selected.
Very high PIP were clearly exceeded with over
distance while
lower peeps,
especially Zip,
was seated with,
at elective and lung collapse. But there were
some patients in who it was 5,
10, 16,
Sue.
In the first approach, you might select to
(15:13):
peep, let's say, between 12
14, 15.
But once again,
this might be adapted,
and, I will talk through about a bit
about monetary,
at the end of
of the talk.
The respiratory rate, well, also, clear data,
gathered during the lung safe
(15:34):
epidemiologic analysis
for large,
surveys of patients,
ARDS patients on mechanical ventilation, and was the
first time that the respiratory rate was disease
mortality.
And, the difference is actually, quite significant here.
Mortality increased by 3% for additional breaths per
minute.
This is probably a threshold, let's say, between
(15:56):
25,
26, 27 above which this becomes highly significant.
But setting up, the respiratory to go 3
or at 35,
is clearly, associated with higher mortality. And this
holds true also for patients on,
veno venous ECMO.
And these,
some indirect data, this is a very,
(16:19):
smart animal
experiment
in peaks,
which were ventilated
using the so called the ARIA strategy,
with the same level of peak, which was
around 10.
And the two groups differed only by one
factor, which was the respiratory rate. In control,
peaks, the rate was 30 per minute,
(16:42):
and, they used ECCOIR,
to reach
14,
breaths per minute
while controlling,
c o two clearance
by
the
vent. But since the minute ventilation was decreased
on the vent,
the extra
(17:04):
c o two was cleared in,
experimental animals with the ECCO device.
And, in that very short
study period of time was, the study experiment
was
just a couple of hours,
and they measured,
the pro inflammatory cytokines boost in the blood
(17:24):
and in the BIL fluid. And it would
last,
actually, last pro inflammatory cytokines in blood and
BAL,
in, the
pigs,
in which the respiratory was decreased to 14.
So
once again, confirming what is
being called biotrauma here,
in,
which is clearly a component of a ventilator
(17:46):
induced like the injury.
The latest,
which may also become a target for mechanical
ventilation
boost,
in the RDS patient and, of course, in
patients,
on venous
ECMO is the mechanical
power,
which is the global energy, which is transferred,
(18:08):
to the lungs, and, the alveoli
by the vent.
This partner and to raise the tidal volume,
the driving pressure,
the fluid PEEP, which is a static component,
of this energy and the respiratory agent of
those parameters.
It's once again probably the driving pressure, which
has the strongest
(18:30):
impact, on,
the wood energy
with the respiratory rate being the the second,
in terms of the importance here. The formula
is quite complicated, but there's a
simplified formula which might be
calculated by the vent itself at the bedside.
And,
(18:50):
there's some data also suggesting that there also
may be a threshold for the mechanical power.
Here is an adjusted. You may adjust that
to,
the specific elastance of the respiratory system,
for example, or the predictive body weight of
the patient. And
in that study here, which is a reanalysis
(19:12):
of large,
randomized studies,
it seemed that there was a threshold
around 17 18 of,
joules per minute to see a unit of
the energy of the mechanical power here, above
which,
there was a significant
increase
in mortality.
And, once again, back to our lifeguard,
(19:33):
who works here,
350
patient of ECMO.
And when looking back at, the VANS setting
just before ECMO and, what was
applied to the patient on day 1,
the draw the mechanical power, as you can
see, he was clearly highly elevated above 20,
so above the
so called threshold of,
(19:55):
a silo with higher mortality. And, obviously, by
decreasing the title to very low levels, same
for the driving pressure, the respiratory,
the mechanical power, becomes very low, less for
fuller than 10 around 5
joules per minute once echo, has been
initiated.
So the next step
(20:15):
might be moving to apneaic ventilation
here
to have,
0 of driving,
just some,
CPAP or,
PEEP
being applied,
to, the patient. And for now, there's no
convincing,
data in humans, but, there's been some, animal
(20:37):
data again
in in a model of of peak here,
showing that this near apnea ventilation
was
a very low,
respiratory rate, very low
tidal volume
was the condition which was associated with,
less, damage
(20:58):
damage,
to, to the lungs.
So this is the next,
area for research now, and we might discuss
that, of course, at the end of,
in this lecture.
Okay.
ECMO also,
since it's
a loose gas exchange from the, trap or
a log,
(21:19):
a membrane log, it will lose to decrease,
the ventilator FiO2,
which may be associated with less toxicity from
high level of oxygen and also,
preventing a trojanation and select disease, which may
occur, if there is
very high FiO2
used on the mechanical ventilators.
(21:39):
So this is something also which is
clearly
demonstrated
and the objective is
(22:03):
It might be decreased over time when the
patient improves, but, the objective is first to
decrease the FIO 2 on the vent,
leaving the f m o two on the
mamrilang,
at 100% at the beginning
of,
the,
f Moran.
There is another question, which is, still a
(22:24):
matter of,
debate.
Should we let the patient risk, or should
we
use deep sedation or pyrolysis here,
to,
completely abolish,
spontaneous ventilation?
Well, when looking back to the literature,
there's some papers showing that it may be
(22:45):
good to have
some, spontaneous ventilation to preserve,
respiratory,
muscle,
especially the diaphragm function, and we might be
also associated with a better VAQ match and
regional ventilation.
And
well, this is something we try to apply
to our patient,
(23:05):
using the APRV mode, which is a form
of BiPAP in which,
there is no synchronization of the respiratory
force
of the patient,
and the 2 levels of pressures, which are
generated
by the ventilator.
So it prevents,
the,
very high,
swings of, transferratory
(23:27):
pressure, which is
sometimes encounters in patients who have the regular
forms of BiPAP in which every spontaneous support
of the patient
leads to
an opening of the valves and
respiratory movement here. The patient can breathe on
top of the two levels of
pressures, but once again, there's no synchronization and
(23:48):
maybe less risks
of
transparent pressure swings here,
in, the patient. So this is the
ventilatory mode we,
applied,
to our,
ECMO
patients.
Setting up the peep once again,
let's say, between 12 and 15, the beginning
(24:09):
and targeting a driving,
between 10 12,
maybe for so less than 15 here,
and,
monitoring the respiratory rate. If the patient is,
having
a deep
respiratory fort and strong respiratory drive, this might
be an indicator of the need for,
(24:32):
a paralyzing agents or deep sedation at least
for the 1st days. And this is something
that we also should have observed during the
COVID, those patient at the very strong,
respiratory drive with a very high,
respiratory rate and also a very
deep and strong respiratory reports, which might have
(24:52):
been associated with,
VD. So,
obviously, if it's the case, the patient might
be paralyzed initially. But once it's possible, this,
APRV mode,
is probably
one good solution, although we need
more studies also to prove that.
(25:13):
The last point on APRV was originally described
by,
releases of pressures. Most of the time, the
patient was on the high level of pressure.
We do not use APRV that way. We
use APRV with a classical,
1 to 2,
inspiratory to, expiratory
ratio.
(25:33):
Well,
and what actually we did in the OLEA,
OLEA was launched, more than 10 years ago
now, and we included the patients,
with, 3 entry criteria, the below 50 for
more than 3 hours or below 80 for
more than 6. And there was also a
search criteria of respiratory,
(25:53):
ACDU disease with the PACU to over 60
for more than 6 hours.
And most of these patients had a very
low,
compliance
and,
needed,
also very high respiratory rate,
to,
reach these,
p c o two objectives. And
what we did in Neolia was
(26:15):
to use
a
coagulation and,
settings of the Maven event were either volumetric
control
with a people of a 10 and the
set to reach a p plat below 24
or,
the pressure control mode was mostly the APRB
mode with the same,
level of pressures. And, well, if you have
(26:35):
the same objective in terms of driving,
peep,
well,
at the end, you have just the same
type of volume, and, there was no,
also recommendation to decrease the respiratory
to 10:10 to 15 as it's the case
in the ELSO,
recommendations
here. It was a bit more liberal here
(26:56):
for the respiratory.
So, well,
showed that there was
a trend towards a benefit
in mortality with ECMO, and it was also
when looking at the secondary endpoints,
there was a benefit in each of those
secondary end points regarding the days
free of valve pressers, free of cardio,
(27:18):
of,
cardiac failure, dialysis, renal failure, and the prone
positioning and and nitric oxide.
This is here, well, what we did,
the title was at 6,
initially as expected for severe ARDS patients, and
it was decreased below 4. It was around,
3.5,
during, the 1st days of ECMO. Same for
(27:40):
the plateau, which was around 30. Initially, it
was decreased to to around 24.
While the PEEP,
was maintained,
virtually the same in both group, it was
around 11 to 12 in the 1st days
of ECMO. And, obviously, decreasing the
title than the plateau while maintaining the PEEP,
We ended up with a much lower driving
(28:01):
pressure. It was around 18,
at and,
it was decreased decreased to around 13,
once the patient was on.
Also, those patients on ECMO was possible to
decrease the PA CO 2 to increase the
oxygen saturation,
(28:21):
and to
increase the pH
as well
as expected with this type of machine center.
This is the primary endpoint here as you
can see,
the, was a trend, p value was 0.07
with,
mortality being, 35 in equipations and 46 in
controls.
(28:43):
We have also a key secondary,
which
was,
tests for echo patients. So that's the need
for a crossover,
in controls.
And this time, there was
a major difference significant difference between the two
groups.
As frequently
done now we also
use bias and stats
(29:03):
to
reanalyze
the results of Eovia and
with these statistical
methods, it was
concluded that the probability of ECMO saving lives
in ECMO patients was very high actually,
above
90% for most of the hypothesis
(29:24):
and this is the reason why Direct Angus
concluded from,
that reanalysis
that, well, clinicians and researchers should no longer
ask does ECMO work?
Because clearly, that question now appears to be
answered. Yes. ECMO works. Now we need to
know by how much will might work cost
and maybe to improve,
(29:44):
some,
management also. And the next question, which came
after Ionia,
was,
the proposition.
We had
some convincing
evidence from,
the ERDS literature of benefit of,
and
especially for those who had the most severe
forms.
And this is the
(30:05):
reason why we launched the product mostly,
pruning,
venous ECMO patients. This is obviously more complicated
than doing this
in, non ECMO patients, but it's feasible. It's
possible.
You need at least 6 p 6 people
to,
roll over a patient in the bed and
(30:26):
put the patient,
pruned,
and you need to protect also the patient
from pressure source. And this is here,
the face mask we use, to protect the
the skin and
the face of the patient.
So, well, once again, there was
(30:47):
an hypothesis here of combining, veno venocectal, which
in the showed that there was a trend
for
mortality benefit together with,
the
study
in
regular ARDS patients. And, well, we did the
study. It was mostly during the COVID 19
pandemic,
(31:07):
and,
the report was published in JAMA a couple
weeks ago.
And, well, the study was negative.
The primary endpoint
was,
the
successful winning of ECMO,
within the 1st 60 days after randomization, and,
actually, it was no difference, between,
patient were pruned and not pruned.
(31:29):
There was no difference also in mortality,
in that study,
which had included 170
patients. Well, once again, it's very specific year
of,
COVID 19 patients.
They represented
90%
of the,
included patients here,
And, well,
this form of ARDS was
(31:51):
not the classical form of ARDS and specifically
because
of the very prolonged acmoron we had, in
these patients, which was an average 3 to
4 weeks.
And in PRONEC, we did only 4 sets,
4 days
of PRONEC positioning
at the very beginning
of the ECMO run. So this might explain
(32:13):
why there was no
benefit here, and, there was no subgroup,
also in which, there was a trend towards
a benefit. So,
should we continue to prone patients?
Definitely, I don't know.
Personally, I believe that there might be some
patient who might benefit,
especially those who have the so called low
bar
(32:34):
ARDS,
those who have consolidation may be the dependent
partial origins of,
of the lungs. Those patients might benefit from
being pruned.
This might not be the case of patients
who had diffuse
confluent,
lesions,
as were was the case for most of
the, COVID 19 patients.
(32:56):
One of the last points,
was is monitoring, especially,
the initial monitoring of PEEP setting. This is
a one paper,
review people who published last year about that.
I've showed you some
pictures of, the EIT. If you have access
to that technique in your ICU,
during the 1st days of ECMO, this is
(33:18):
actually probably a very good one,
to
set up the best peep. It's not invasive.
It's
used at the bedside, graduation free,
and it's also dynamic
assessment of the of the lungs with direct
images
here provided by by by the machine.
(33:39):
But it's only one region. It's just a
cross section of,
one slice of of the lung and,
well, it's still time consuming,
and, the the machine is still
not available in our ICUs.
One of the best technique is,
the,
thoracic,
CT,
(34:00):
in which you might also use
a a PEEP trial here, but definitely here,
it's quite complicated to, get the patient to,
do is very sick patients and,
to to the, radiological,
lab to to have,
CT. And
the other technique which might be used is
the,
primary pressure guided with the,
(34:23):
the fragile
balloon and probe here, to, monitor
the transfer pressure.
This might not be actually
one good
solution,
although there's some,
artifacts also with this technique and
(34:43):
setting up the the the right
0 is is sometimes a bit cumbersome here
and
the the the the the the prove might
move, etcetera. So, there's some also drawbacks with
that, but it's probably,
the technique which is the the most simple
at the bedside.
Last,
well,
probably, it's better not to ventilate at all
(35:05):
patient to let them extubate it. I talked
to you about
the the ventilation, but another solution would be
to constantly extubate the patient.
This has been called AWAKE,
ECMO.
That's
worked in the literature, but it's well, when
looking, it's mostly for patients who have bridged,
(35:27):
to lung transplantation. The very few, ERD patients
were able to sustain
spontaneous spontaneous
bracing,
and getting extubated
on ECMO. There was a small
study
in a group
working in Rush University, which is very close
to Chicago,
during COVID 19, which, actually activate their patients
(35:50):
after 10,
15 days.
And the patient got an extra,
2 weeks of, ECMO awake,
and they got good results but it's
probably one of the only group in which
it was
reported here so
well it's probably for very severe ARDS
not very
easy
(36:12):
to have those patients completely
extubated.
So, to sum up,
ECMO,
allows you to markedly reducing
intensity of mechanical ventilation, and this is probably
the way, it improves the survival of the
patients.
In most cases, once again, the the patients
(36:32):
were dying of
hypoxemia,
very,
low
compliance, high elastance here in need of a
rare high precious
is much less frequent.
And,
this is clearly the paradigm here, which is
using
ECMO patients to reduce VV.
(36:52):
And the targets here, the title is usually
much lower than 4, and it's
the most severe forms. It's usually below 1
and sometimes,
almost virtual here,
with the driving, which should be for 4
less than 15. Our target is 10:12,
around 10, 12, now.
And,
if possible, also, it might be interesting to
(37:14):
decrease respiratory rate while PEEP
might be the best scenario is to adjust
PEEP to,
the need of each patient, but once again,
it's not that
easy at the bedside.
A simple,
P trial measuring
exchange
and,
(37:34):
the respiratory mechanics of the patient might help
without any other technique. And it's also very
easy to measure,
the airway opening pressure if it exists
to
to set up the peep just above that
we,
of the impression. Still many, many questions from
(37:54):
Amy.
Is it possible
to reach near apnea ventilation? This is something
we may test here in the future trial
in our unit.
Is it better, using volume,
assisted ventilation
pressure mode, something also which may be the
target of a future trial? And,
(38:16):
well,
group positioning
clearly remains,
a major issue because, once again, we tested
that
mostly in COVID 19 patients and probably does
not answer,
the question for the called more regular,
ARDS
patients.
Well,
(38:37):
with that, we'd like to thank you very
much for listening, and we may discuss,
now, for a couple minutes, the questions you
might have.
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