What are the ventilation guidelines for a patient with Extracorporeal Cardiopulmonary Resuscitation (ECCOR2)?

Ventilation Guidelines in ECCO2R Patients

In patients receiving extracorporeal CO2 removal (ECCO2R), implement ultra-protective ventilation with tidal volumes of 3-4 mL/kg predicted body weight, plateau pressures maintained at 23-25 cmH2O, and PEEP of 4-8 cmH2O (or higher at 10-15 cmH2O), while targeting normocapnia and avoiding hyperventilation. 1, 2, 3

Core Ventilation Parameters During ECCO2R

Tidal Volume Strategy

• Target tidal volume of 3-4 mL/kg predicted body weight when ECCO2R is initiated, which is significantly lower than standard lung-protective ventilation (6 mL/kg) 2, 3, 4
• The reduction to ultra-low tidal volumes (≤3 mL/kg) is feasible in approximately 40% of patients and is more successful with higher ECCO2R blood flow rates (>400 mL/min) 4
• Document all tidal volumes as mL/kg predicted body weight for standardization 5

Plateau Pressure and Driving Pressure

• Maintain plateau pressure between 23-25 cmH2O during ECCO2R therapy 2, 3
• Driving pressure (plateau pressure minus PEEP) should be reduced to approximately 8-12 cmH2O, which represents a significant reduction from conventional protective ventilation 2, 3
• Continuously assess plateau pressure to ensure lung-protective settings 5

PEEP Management

• Increase PEEP to 14-15 cmH2O when reducing tidal volumes to maintain alveolar recruitment 2, 3
• During extracorporeal support, use PEEP greater than 10 cmH2O to maintain alveolar inflation and prevent pulmonary edema and atelectasis 6
• The higher PEEP compensates for the ultra-low tidal volumes and prevents derecruitment 2

Gas Exchange Targets

CO2 Management

• Target normocapnia (PaCO2 40-45 mmHg or ETCO2 35-40 mmHg) as the standard approach 7
• Mild respiratory acidosis is acceptable during ECCO2R initiation, with PaCO2 increases up to 53 mmHg and pH decreases to 7.32 being tolerated 3
• ECCO2R should be initiated when pH drops below 7.25 with PaCO2 >60 mmHg despite optimized ventilation 1
• Avoid hyperventilation and hypocapnia (Class III recommendation), as this causes cerebral vasoconstriction and decreased cerebral blood flow, worsening brain ischemia 7

Oxygenation Targets

• Titrate FiO2 to maintain arterial oxygen saturation of 94-98% once reliable monitoring is established 7
• Target oxygen saturation of 88-92% in patients with risk factors for hypercapnic respiratory failure 8
• Avoid early hyperoxia (PaO2 >300 mmHg), which is associated with increased mortality and poor neurological outcomes 6

Respiratory Rate and Minute Ventilation

• Do not increase respiratory rate to compensate for low tidal volumes during ECCO2R therapy 3
• The ECCO2R device provides CO2 clearance, eliminating the need for high minute ventilation 2, 3
• Typical ECCO2R systems remove 50-60 mL/min of CO2 with blood flows of 400-450 mL/min and sweep gas flows of 10 L/min 2, 3

Monitoring Requirements

Continuous Assessment

• Monitor arterial blood gases every 4-6 hours to assess gas exchange and adjust ventilator settings 8
• Continuously monitor arterial blood pressure and respiratory parameters 1, 8
• Assess plateau pressure, PEEP, and auto-PEEP regularly 5
• Track driving pressure to prevent ventilator-induced injury 5

Daily Evaluations

• Perform daily echocardiography to assess cardiac function, particularly right ventricular function 8
• Monitor for signs of left ventricular distension, which can occur with increased afterload 6
• Track fluid balance meticulously, targeting daily negative fluid balance once hemodynamically stable 6

Critical Pitfalls to Avoid

Hyperventilation

• Never hyperventilate patients on ECCO2R - this increases intrathoracic pressure, decreases venous return, and worsens cerebral perfusion 7
• Excessive ventilation with high tidal volumes or rates causes hemodynamic instability and reduces cardiac output 7

Excessive Tidal Volumes

• Avoid delivering tidal volumes >6 mL/kg when ECCO2R is in place, as this negates the lung-protective benefits 2, 3
• Use only the force necessary to achieve minimal chest rise 7

Inadequate PEEP

• Failure to increase PEEP when reducing tidal volumes leads to atelectasis and derecruitment 2
• PEEP <10 cmH2O is generally insufficient during ultra-protective ventilation with ECCO2R 6

Sedation and Neuromuscular Blockade

• Administer adequate sedation to reduce oxygen consumption and improve patient-ventilator synchrony 7
• Short-term neuromuscular blockade (≤48 hours) may be required to prevent patient-ventilator dyssynchrony during ultra-protective ventilation 7
• Use continuous EEG monitoring if neuromuscular blockade is employed to detect seizures 7
• Implement sedation protocols with daily interruptions when feasible 7

Weaning Considerations

• Consider weaning from ECCO2R when PaO2/FiO2 ratio exceeds 200 and the patient can tolerate conventional ventilation settings 2
• Monitor for rebound hypercapnia in the immediate post-ECCO2R period with arterial blood gases every 4-6 hours 8
• Gradual weaning of ventilatory support with close monitoring of work of breathing is essential 8