Effect of Driving Pressure Change During Extracorporeal Membrane Oxygenation in Adults With Acute Respiratory Distress Syndrome: A Randomized Crossover Physiologic Study*

Abstract

Objectives: Venovenous extracorporeal membrane oxygenation is an effective intervention to improve gas exchange in patients with severe acute respiratory distress syndrome. However, the mortality of patients with severe acute respiratory distress syndrome supported with venovenous extracorporeal membrane oxygenation remains high, and this may be due in part to a lack of standardized mechanical ventilation strategies aimed at further minimizing ventilator-induced lung injury. We tested whether a continuous positive airway pressure ventilation strategy mitigates ventilator-induced lung injury in patients with severe acute respiratory distress syndrome on venovenous extracorporeal membrane oxygenation, compared with current ventilation practice that employs tidal ventilation with limited driving pressure. We used plasma biomarkers as a surrogate outcome for ventilator-induced lung injury. Design: Randomized crossover physiologic study. Setting: Single-center ICU. Patients: Ten patients with severe acute respiratory distress syndrome supported on venovenous extracorporeal membrane oxygenation. Interventions: The study included four phases. After receiving pressure-controlled ventilation with driving pressure of 10 cm H2O for 1 hour (phase 1), patients were randomly assigned to receive first either pressure-controlled ventilation 20 cm H2O for 2 hours (phase 2) or continuous positive airway pressure for 2 hours (phase 3), and then crossover to the other phase for 2 hours; during phase 4 ventilation settings returned to baseline (pressure-controlled ventilation 10 cm H2O) for 4 hours. Measurements and Main Results: There was a linear relationship between the change in driving pressure and the plasma concentration of interleukin-6, soluble receptor for advanced glycation end products, interleukin-1ra, tumor necrosis factor alpha, surfactant protein D, and interleukin-10. Conclusions: Ventilator-induced lung injury may occur in acute respiratory distress syndrome patients on venovenous extracorporeal membrane oxygenation despite the delivery of volume- and pressure-limited mechanical ventilation. Reducing driving pressure to zero may provide more protective mechanical ventilation in acute respiratory distress syndrome patients supported with venovenous extracorporeal membrane oxygenation. However, the risks versus benefits of such an approach need to be confirmed in studies that are designed to test patient centered outcomes.

Effect of positive end-expiratory pressure on lung injury and haemodynamics during experimental acute respiratory distress syndrome treated with extracorporeal membrane oxygenation and near-apnoeic ventilation

“… 15 A recent randomised crossover physiological study in 10 patients with ARDS on ECMO confirmed those results, showing that even 10 cm H 2 O of driving pressure applied during ultra-protective ventilation may increase biotrauma, compared with a strategy with zero driving pressure. 3 However, differences observed in the present study cannot be explained by differences in driving pressure or mechanical power, as these variables were comparable between the three study groups and within ranges usually considered as safe. A possible explanation is that driving pressure and mechanical power reflect the global mechanical burden of mechanical ventilation, but they may not reflect the presence of VILI at the regional level.…”

“…Studies have shown that further limiting V T and driving pressures in patients with ARDS with the use of ECMO may be beneficial. 1 , 2 , 3 …”

Individualized Multimodal Physiologic Approach to Mechanical Ventilation in Patients With Obesity and Severe Acute Respiratory Distress Syndrome Reduced Venovenous Extracorporeal Membrane Oxygenation Utilization

“…In the SOC cohort, VV ECMO allowed an ultraprotective mechanical ventilation strategy with tidal volumes well below 6 mL/kg of ideal body weight ( 22 – 24 ). PEEP and overall respiratory system compliance remained unchanged during the first 5 days after the intervention (Fig.…”

“…Furthermore, definitive data are still missing on the use of an ultraprotective lung ventilation strategy during VV ECMO, compared with standard ARDSnet tidal volume calculations. However, recently, Del Sorbo et al ( 24 ) demonstrated that there was a linear relationship between tidal volume and plasma biomarkers of ventilator-induced lung injury, whereas Costa et al ( 37 ) found that among ventilator variables, only driving pressure and respiratory rate had significant associations with mortality.…”

Ventilator-Associated Lung Injury

“…However, a time-dependent analysis showed that higher tidal volume and lower driving pressure (both suggesting resolution of pulmonary mechanics and function) was associated with survival. More recently, it has been shown that even on ECMO there are reductions in surrogate systemic biomarkers of VALI when the ventilation strategy is modified ( Sorbo et al, 2020 ). Sorbo et al showed linear reductions in the plasma concentrations of interleukin(IL)-6, soluble receptor for advanced glycation end products, IL-1ra, tumor necrosis factor alpha, surfactant protein D, and IL-10 with changes in driving pressure on ECMO.…”