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