Biotrauma during ultra-low tidal volume ventilation and venoarterial extracorporeal membrane oxygenation in cardiogenic shock: a randomized crossover clinical trial

Abstract

Background Cardiogenic pulmonary oedema (CPE) may contribute to ventilator-associated lung injury (VALI) in patients with cardiogenic shock. The appropriate ventilatory strategy remains unclear. We aimed to evaluate the impact of ultra-low tidal volume ventilation with tidal volume of 3 ml/kg predicted body weight (PBW) in patients with CPE and veno–arterial extracorporeal membrane oxygenation (V–A ECMO) on lung inflammation compared to conventional ventilation. Methods A single-centre randomized crossover trial was performed in the Cardiac Intensive Care Unit (ICU) at a tertiary university hospital. Seventeen adults requiring V–A ECMO and mechanical ventilation due to cardiogenic shock were included from February 2017 to December 2018. Patients were ventilated for two consecutive periods of 24 h with tidal volumes of 6 and 3 ml/kg of PBW, respectively, applied in random order. Primary outcome was the change in proinflammatory mediators in bronchoalveolar lavage fluid (BALF) between both ventilatory strategies. Results Ventilation with 3 ml/kg PBW yielded lower driving pressures and end-expiratory lung volumes. Overall, there were no differences in BALF cytokines. Post hoc analyses revealed that patients with high baseline levels of IL-6 showed statistically significant lower levels of IL-6 and IL-8 during ultra-low tidal volume ventilation. This reduction was significantly proportional to the decrease in driving pressure. In contrast, those with lower IL-6 baseline levels showed a significant increase in these biomarkers. Conclusions Ultra-low tidal volume ventilation in patients with CPE and V–A ECMO may attenuate inflammation in selected cases. VALI may be driven by an interaction between the individual proinflammatory profile and the mechanical load overimposed by the ventilator. Trial registration The trial was registered in ClinicalTrials.gov (identifier NCT03041428, Registration date: 2nd February 2017).

Ultra-lung-protective ventilation and biotrauma in severe ARDS patients on veno-venous extracorporeal membrane oxygenation: a randomized controlled study

“…Last, Amado‑Rodríguez et al did not find differences in numerous inflammatory biomarkers sampled by BAL between ventilation protocol with Vt of 3 or 6 mL/kg of PBW during 24 h in patients supported by veno-arterial ECMO for cardiogenic shock [ 23 ].…”

Transcriptomic clustering of critically ill COVID-19 patients

“…Clustering strategies have been proposed to identify different subgroups of critically ill patients with respiratory failure that may help to personalise treatments. In ARDS, a hyperinflammatory/reactive phenotype [ 9 , 35 ], characterised by markers of acute inflammation and tissue hypoxia, has been linked to higher mortality rates and could specifically benefit from fluid restriction, higher PEEP levels or protective ventilation [ 36 ], in contraposition to the uninflamed phenotype. Of note, causes of ARDS were different between phenotypes, with a higher incidence of sepsis in the hyperinflamed/reactive group.…”

Determinants of Arterial Pressure of Oxygen and Carbon Dioxide in Patients Supported by Veno-Arterial ECMO

“…Ventilator parameters, such as respiratory rate, ventilatory FiO 2 , or PEEP, were not associated with patient homeostasis. Nevertheless, studies have demonstrated that ventilatory parameters should be set to avoid lung trauma [ 36 ]. In other words, physicians should consider using protective ventilation with low FiO 2 and low respiratory rate in patients supported by VA ECMO without any concerns about patient oxygenation or CO 2 removal.…”