Mechanical Ventilation in Patients with the Acute Respiratory Distress Syndrome and Treated with Extracorporeal Membrane Oxygenation: Impact on Hospital and 30 Day Postdischarge Survival

Modrykamien, Ariel; Hernandez, Omar; Im, Yunhee; Walters, Ryan W.; Schrader, Caleb L.; Smith, L.; Lima, Brian

doi:10.1097/mat.0000000000000406

Cited by 15 publications

(10 citation statements)

References 19 publications

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“…High-PEEP strategies in adult studies have reported divergent outcomes. [6][7][8][9]29 Higher PEEP in neonates leads to shorter ECMO duration and fewer complications. 11,30 However, low PEEP was defined as 4-6 cm H 2 O. PEEP this low was rarely seen in our study and is not commonly used in pediatric ECMO.…”

Section: Discussionmentioning

confidence: 99%

Mechanical Ventilation in Children on Venovenous ECMO

et al. 2020

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BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used when mechanical ventilation can no longer support oxygenation or ventilation, or if the risk of ventilator-induced lung injury is considered excessive. The optimum mechanical ventilation strategy once on ECMO is unknown. We sought to describe the practice of mechanical ventilation in children on VV-ECMO and to determine whether mechanical ventilation practices are associated with clinical outcomes. METHODS: We conducted a multicenter retrospective cohort study in 10 pediatric academic centers in the United States. Children age 14 d through 18 y on VV-ECMO from 2011 to 2016 were included. Exclusion criteria were preexisting chronic respiratory failure, primary diagnosis of asthma, cyanotic heart disease, or ECMO as a bridge to lung transplant. RESULTS: Conventional mechanical ventilation was used in about 75% of children on VV-ECMO; the remaining subjects were managed with a variety of approaches. With the exception of PEEP, there was large variation in ventilator settings. Ventilator mode and pressure settings were not associated with survival. Mean ventilator F IO 2 on days 1-3 was higher in nonsurvivors than in survivors (0.5 vs 0.4, P 5 .009). In univariate analysis, other risk factors for mortality were female gender, higher Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS), diagnosis of cancer or stem cell transplant, and number of days intubated prior to initiation of ECMO (all P < .05). In multivariate analysis, ventilator F IO 2 was significantly associated with mortality (odds ratio 1.38 for each 0.1 increase in F IO 2 , 95% CI 1.09-1.75). Mortality was higher in subjects on high ventilator F IO 2 (6 0.5) compared to low ventilator F IO 2 (> 0.5) (46% vs 22%, P 5 .001). CONCLUSIONS: Ventilator mode and some settings vary in practice. The only ventilator setting associated with mortality was F IO 2 , even after adjustment for disease severity. Ventilator F IO 2 is a modifiable setting that may contribute to mortality in children on VV-ECMO.

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Section: Discussionmentioning

confidence: 99%

Mechanical Ventilation in Children on Venovenous ECMO

et al. 2020

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“…The lowest mortality was observed in studies reporting a combination of low plateau pressures (≤ 26 cm H 2 O) and low tidal volumes (≤ 4 ml/kg) [4]. An increase in Pplat by 1 cm H 2 O in patients on ECMO decreases the odds of hospital survival by 21% [41].…”

Section: Plateau Pressurementioning

confidence: 99%

Ventilatory management of patients on ECMO

Singh

Hote

2020

Indian J Thorac Cardiovasc Surg

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Extracorporeal membrane oxygenation (ECMO) is the final treatment offered to patients of acute respiratory distress syndrome (ARDS). The survival (to discharge) of patients on veno-venous ECMO is approximately 59% with an average duration of 8 days. The ventilatory management of lungs during the ECMO may have an impact on mortality. An ideal ventilation modality should promote recovery, prevent further damage to the alveoli, and enable weaning from mechanical ventilation. This article reviews the concept of "baby lung" in ARDS and the current evidence for the use of lung protective ventilation, prevention of ventilator-induced lung injury, recommended modes of mechanical ventilation, ideal ventilatory parameters (tidal volume, positive end expiratory pressure, plateau pressure, respiratory rate, fractional inspired oxygen concentration), and use of adjuncts (prone positioning, neuromuscular blocking agents) during the ECMO course.

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“…73 Conversely, a higher average PEEP was associated with reduced survival in another cohort. 74 Only 27% of centers report using spontaneous modes of ventilation on VV-ECMO patients. 64 This may be because "safe" spontaneous breathing is difficult to achieve in ARDS patients, even on ECMO.…”

Section: Mechanical Ventilation During Vv-eclsmentioning

confidence: 99%

Extracorporeal Strategies in Acute Respiratory Distress Syndrome

Cavayas

Thakore

Fan

2019

Semin Respir Crit Care Med

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Despite the breadth of life-sustaining interventions available, mortality in patients with acute respiratory distress syndrome (ARDS) remains high. A greater appreciation of the potential iatrogenic injury associated with the use of mechanical ventilation has led clinicians and researchers to seek alternatives. Extracorporeal life support (ECLS) may be used to rescue patients with severely impaired gas exchange and provide time for injured lungs to recover while treating the underlying disease. In patients with ARDS, venovenous (VV) ECLS is commonly used, where venous blood is drained into a circuit that passes through a membrane lung, which provides gas exchange, and then returned to the venous system. VV-ECLS can be configured as a system that uses higher blood flows with extracorporeal membrane oxygenation (VV-ECMO) or as one that uses lower blood flows for extracorporeal carbon dioxide removal (VV-ECCO2R). Recent studies support the use of VV-ECMO in patients with severe ARDS who present with refractory gas exchange despite the use of lung-protective mechanical ventilation, positive end-expiratory pressure optimization, neuromuscular blockade, and prone positioning. The optimal management of patients during ECLS (i.e., anticoagulation, transfusions, mechanical ventilation) and the role of ECCO2R in the management of ARDS remain to be determined.

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Mechanical Ventilation in Patients with the Acute Respiratory Distress Syndrome and Treated with Extracorporeal Membrane Oxygenation: Impact on Hospital and 30 Day Postdischarge Survival

Cited by 15 publications

References 19 publications

Mechanical Ventilation in Children on Venovenous ECMO

Mechanical Ventilation in Children on Venovenous ECMO

Ventilatory management of patients on ECMO

Extracorporeal Strategies in Acute Respiratory Distress Syndrome

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