ICS SOA 2015

1. ECMO:
You’re doing it wrong
2015, London
Luciano Gattinoni, MD, FRCP
Università di Milano
Fondazione IRCCS- “Ospedale Maggiore
Policlinico, Mangiagalli, Regina Elena”
Milan, Italy

2. Control of breathing using an
extracorporeal membrane lung
Kolobow T, Gattinoni et al., Anesthesiology, 1977; 46: 138-141
The lung rest concept

3. Kolobow et al Trans. Am. Soc. Artif. Intern. Organs. 1977. 23: 17-21

4. Gattinoni et al Anest. e Rianim. 1977. 18(4): 396-406

5. OXYGENATION
FiO2 =1.0 250 mL min-1
CO2 REMOVAL
VA 9500 mL min-1
VO2
250
mL min-1
VCO2
200
mL min-1
Sata 98%
PaO2 110 mmHg
CO2 cont 34 mL
PaCO2 15 mmHg
Hb 15 g
Satv 82%
PvO2 47 mmHg
CO2 cont 52 mL
PvCO2 43 mmHg
7000 mL min-1
PBF
1100 mL min-1
PBF
Gattinoni et al., European Advances in Intensive Care, 1983; 21: 97-117

6. Healthy subject
Moderate ARDS
Severe ARDS
Average ratio in normal subjects : 1.37±0.15

7. Ki/lung inhomogeneity interaction and gas/tissue
composition
MILD
MODERATE
SEVERE

8. Depending on EL/Ers, for the same
driving pressure, the
transpulmonary pressure may be
Too High Dangerous
Too Low Dangerous

9. PL too High
Tidal Volume reaches TLC PL>24
cmH2O
PL>12 cmH2O in unhomogeneous lung
stress risers X2
or
VILI

10. PL too Low
Insufficient total ventilation
PCO2 rise, pH decrease
Progressive atelectasis
Worsening hypoxemia
Increased pulmonary hypertension
Right ventricular failure

11. Tidal Strain
P*ΔV = Energy Input
Dissipated Undissipated
Surface Tension
Sliding EM
Opening and Closing
Elastic System
PEEP *ΔV = Energy Input = 0
Continuous Strain

12. Pressure
0 10 20 30 40 50 60
Volume
0
200
400
600
800
1000
1200
PEEP
Peak
Pressure
PEEP Volume
Total Inspiratory Volume
Pressure
0 10 20 30
Volume
0
200
400
600 ZEEP
Peak
Pressure
Total Inspiratory Volume
Pressure
0 10 20 30 40
Volume
0
200
400
600
800
1000
1200
PEEP
Peak
Pressure
PEEP Volume
Total Inspiratory Volume
EXAPLES OF ENERGY
COMPUTATIONS AT
DIFFERENT PRESSURES
ZEEP
LOW PEEP HIGH PEEP