Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort.

Schmidt, Matthieu;Pham, Tài;Arcadipane, Antonio;Agerstrand, Cara;Wittebole, Xavier;et.al.
(2019) American Journal of Respiratory and Critical Care Medicine — Vol. 200, n° 8, p. 1002-1012 (2019)

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Authors
  • Schmidt, Matthieu
    Author
  • Pham, Tài
    Author
  • Arcadipane, Antonio
    Author
  • Agerstrand, Cara
    Author
  • Pierard, SophieUCLouvain
    Author
  • Jacquet, Luc-MarieUCLouvain
    Collaborator
  • Van Caenegem, OlivierUCLouvain
    Collaborator
  • Wittebole, XavierUCLouvain
    Collaborator
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Abstract
OBJECTIVES: To report current practices regarding mechanical ventilation in patients treated with extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) and their association with 6-month outcomes. METHODS: International, multi-center, prospective cohort study of patients undergoing ECMO for ARDS during a one-year period in 23 international intensive care units (ICUs). MEASUREMENTS AND MAIN RESULTS: We collected demographics, daily pre- and per-ECMO mechanical ventilation settings and use of adjunctive therapies, ICU- and 6-month-outcome data for 350 patients (median ± standard deviation pre-ECMO PaO2/FiO2 71±34 mmHg). Pre-ECMO use of prone positioning and neuromuscular blockers were 26% and 62%, respectively. Tidal volume (6.4±2.0 vs 3.7±2.0 ml/kg), plateau pressure (32±7 vs 24±7cmH2O), driving pressure (20±7 vs. 14±4 cmH2O), respiratory rate (26±8 vs 14±6 breaths/min) and mechanical power (26.1±12.7 vs. 6.6±4.8 J/min) were markedly reduced after ECMO initiation. Six-month survival was 61%. No association was found between ventilator settings during the first 2 days of ECMO and survival in multivariable analysis. A time-varying Cox model retained older age, higher fluid balance, higher lactate, and more need for renal replacement therapy along the ECMO course as being independently associated with 6-month mortality. A higher tidal volume and lower driving pressure (likely markers of static compliance improvement) across the ECMO course were also associated with better outcomes. CONCLUSION: Ultra-protective lung ventilation on ECMO was largely adopted across medium to high case-volume ECMO centers. In contrast with previous observations, mechanical ventilation settings during ECMO did not impact patients' prognosis in this context.
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Schmidt, M., Pham, T., Arcadipane, A., Agerstrand, C., Ohshimo, S., Pellegrino, V., Vuylsteke, A., Guervilly, C., McGuinness, S., Pierard, S., Breeding, J., Stewart, C., Ching, S. S. W., Camuso, J. M., Stephens, R. S., King, B., Herr, D., Schultz, M. J., Neuville, M., et al. (2019). Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort. American Journal of Respiratory and Critical Care Medicine, 200(8), 1002-1012. https://doi.org/10.1164/rccm.201806-1094OC (Original work published 2019)