Page 154 - HA Convention 2015

Masterclasses

MC8.3 Recent Advances in Treatment of Acute Respiratory Diseases 10:45 Theatre 1

Tuesday, 19 May Extracorporeal Membrane Oxygenation (ECMO)/ Extracorporeal Carbon Dioxide Removal (ECCO2R) + Ultra-
protective Lung Ventilation (UPLV)
Yan WW
Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong

Extracorporeal membrane oxygenation (ECMO) is a therapeutic option increasingly used in cardio-respiratory failure
case which is refractory to conventional therapy. It involves the drainage of body venous blood from large cannula to an
oxygenator by a pump. Gas exchange takes place with oxygen added and carbon dioxide (CO2) removed from the blood
inside the oxygenator. The treated blood is then returned to the body venous system via another large bore cannula. It is
called veno-venous ECMO which is used to provide complete respiratory support. There is a variant form of ECMO called
extracorporeal carbon dioxide removal (ECCO2R) which facilitates only CO2 removal and provides only partial respiratory
support. In contrary to the large blood flow required for ECMO which is usually 4 to 6 L/min for an adult, ECCO2R only needs
0.5 to 1 L/min. This low flow requirement allows ECCO2R be done via a smaller-sized double lumen cannula. This greatly
reduces the risk of cannulation complication in relation to ECMO therapy.

For patients with acute respiratory distress syndrome (ARDS), protective ventilatory strategy of using tidal volume 6 to 8
ml/kg is currently used to reduce the risk of ventilator induced lung injury (VILI). However, recent evidence showed that
further reducing the tidal volume to less than 6ml/kg can reduce VILI more. This strategy is labelled as ultra-protective lung
ventilation (UPLV). Because of the further reduction in tidal volume, CO2 accumulation is the main obstacle in employing
UPLV. ECCO2R has been tried to solve this problem and this technique has been found very promising.

While ECCO2R cannot provide adequate oxygenation to the body because of its low flow system, its role in the most severe
ARDS is therefore limited. However, it has a potential role in the treatment of less severe form of ARDS but is still considered
high risk of VILI when treated by conventional mechanical ventilation. There are many on-going studies and the role of
ECCO2R of ARDS will be delineated very soon.

MC8.4 Recent Advances in Treatment of Acute Respiratory Diseases 10:45 Theatre 1

HOSPITAL AUTHORITY CONVENTION 2015 Management of Respiratory Tract Diseases in the Accident and Emergency Department
Ducharme J
Department of Medicine, McMaster University, Canada

In March 2003, the son of the index case of Severe Acute Respiratory Syndrome (SARS) arriving from Hong Kong came to the
emergency department of a Toronto hospital. With fever and dyspnea of an undetermined illness, he stayed in the hallway for
more than 24 hours. While there, two patients and one technician became ill. Because one of those two patients went home
before returning with SARS, he infected the two emergency medical services personnel bringing him back to the hospital.
Ultimately, 36 hospital staff and physicians developed SARS, essentially all due to improper handling and isolation of the
first case. 12 years later, despite illnesses such as Middle East Respiratory Syndrome, Avian Flu, H1N1, Multi-drug-resistant
Tuberculosis, Ebola and SARS, patients and healthcare staff are at as much risk as ever for respiratory tract transmission.
Universal precautions are not applied, while emergency department crowding places undiagnosed patients in close
proximity. In the case of Ebola, mandatory precautions in many countries were inadequate (not using level five biohazard
levels of protection) and gave false perceptions of sufficient steps being taken to prevent spread.

This session will attempt to describe the current risks from these respiratory illnesses for those at the first line of defence
in the accident and emergency department. How we can minimise or eliminate disease transmission at the gateway to the
hospital while maintaining efficiencies of care and while under strict budgetary constraints will be discussed – ultimately
failure to spend money at the front door ensures greater costs overall, and - far worse – greater morbidity and mortality.

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