• Besen Bruno Adler Maccagnan Pinheiro BAMP Unidade de Terapia Intensiva, Disciplina de Emergências Clínicas; Departamento de Clínica Médica; Hospital das Clínicas, Faculda, Thiago Gomes Romano, Rogerio Zigaib, Pedro Vitale Mendes, Melro Lívia Maria Garcia LMG Unidade de Terapia Intensiva, Disciplina de Emergências Clínicas; Departamento de Clínica Médica; Hospital das Clínicas, Faculdade de Medicin, and Marcelo Park.
• Unidade de Terapia Intensiva, Disciplina de Emergências Clínicas; Departamento de Clínica Médica; Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.
• Rev Bras Ter Intensiva. 2019 May 13; 31 (2): 113-121.

ObjectiveTo describe (1) the energy transfer from the ventilator to the lungs, (2) the match between venous-venous extracorporeal membrane oxygenation (ECMO) oxygen transfer and patient oxygen consumption (VO2), (3) carbon dioxide removal with ECMO, and (4) the potential effect of systemic venous oxygenation on pulmonary artery pressure.MethodsMathematical modeling approach with hypothetical scenarios using computer simulation.ResultsThe transition from protective ventilation to ultraprotective ventilation in a patient with severe acute respiratory distress syndrome and a static respiratory compliance of 20mL/cm H2O reduced the energy transfer from the ventilator to the lungs from 35.3 to 2.6 joules/minute. A hypothetical patient, hyperdynamic and slightly anemic with VO2 = 200mL/minute, can reach an arterial oxygen saturation of 80%, while maintaining the match between the oxygen transfer by ECMO and the VO2 of the patient. Carbon dioxide is easily removed, and normal PaCO2 is easily reached. Venous blood oxygenation through the ECMO circuit may drive the PO2 stimulus of pulmonary hypoxic vasoconstriction to normal values.ConclusionUltraprotective ventilation largely reduces the energy transfer from the ventilator to the lungs. Severe hypoxemia on venous-venous-ECMO support may occur despite the matching between the oxygen transfer by ECMO and the VO2 of the patient. The normal range of PaCO2 is easy to reach. Venous-venous-ECMO support potentially relieves hypoxic pulmonary vasoconstriction.

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