Pulmonary Considerations
Management of the pulmonary system during hybrid ECMO includes application of information obtained from cardiac monitors as well as evidence-based maneuvers to decrease the risk of developing primary graft dysfunction (PGD) during the perioperative period. Adequate ETCO2 and pulmonary arterial pulsatility are indicators of right ventricle cardiac output ensuring controlled perfusion of the newly implanted graft during hybrid ECMO. Post lung implantation, the pulmonary venous cuff is evaluated with pulse wave Doppler (PWD) via TEE in order to qualitatively detect the presence of cardiac output within the lung and to identify potential pulmonary vein obstruction. Mechanical ventilation of the lungs on ECMO is based on evidence from the literature, with the goal of minimizing injury to the implanted grafts being achieved using a lung protective approach with fraction of inspired oxygen (FiO2) < 40%.1,8 We also administer inhaled anesthetic via both the hybrid ECMO circuit and the anesthesia machine, as the use of inhaled anesthetics has been shown to decrease formation of pulmonary edema and improve partial pressure of oxygen/FiO2 ratios in animal lung transplantation models.1