Setting and Monitoring of Mechanical Ventilation During Venovenous ECMO

Abstract

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901.

Extracorporeal membrane oxygenation as acute rescue therapy for negative pressure pulmonary edema in the post anesthesia care unit: A case report

“…The classical approach to patients on VV ECMO has been to use “lung‐protective” or “ultra‐lung protective” ventilator settings in order to minimize ventilator‐induced lung injury. However, the optimal ventilation strategy for patients on ECMO is yet to be elucidated, with some centers utilizing “lung rest” while others focusing on “lung recruitment” 14 . A recent study, assessing ventilation management in patients on VV ECMO with acute respiratory distress syndrome, found no significant association between ventilator settings during the first 2 days of ECMO support and survival 14 .…”

“…However, the optimal ventilation strategy for patients on ECMO is yet to be elucidated, with some centers utilizing “lung rest” while others focusing on “lung recruitment” 14 . A recent study, assessing ventilation management in patients on VV ECMO with acute respiratory distress syndrome, found no significant association between ventilator settings during the first 2 days of ECMO support and survival 14 . In this case, we opted for an individualized mechanical ventilation strategy to promote patient comfort, minimize patient‐ventilator desynchrony, and avoid any further lung injury 15 .…”

Retrospective analysis of factors associated with outcome in veno-venous extra-corporeal membrane oxygenation

“…The ventilation strategy to apply during VV-ECMO is presently debated [ 45 ]. Common practice is to reduce V T at 4–6 ml/kg PBW and maintain a PEEP of at least 10 cm H 2 O, in order to keep Pplat and DP below 24 and 14 cm H 2 O, respectively, as reported in the EOLIA trial.…”

“…MP represents a unifying variable measuring the energy delivered by ventilation to the respiratory system, which has been associated with mortality in ARDS. During ECMO, MP markedly decreases, primarily as a result from the reduction of Vt [ 45 ], which may then limit its prognostic significance in this setting. Only a few studies addressed this issue, with conflicting results.…”

“…However, we believe that the current results still provide some interesting insights for the management of patients under VV-ECMO. Current recommendations indicate to target a Vt < 4 ml/kg and a DP < 14 cm H 2 O during VV-ECMO in ARDS patients [ 3 , 21 , 45 ]. The major prognostic impact of driving pressure after 24 h of ECMO reported in our study suggests that a strategy of ultraprotective ventilation, or even near apneic ventilation [ 45 ], could be applied already at the very early stage of ECMO to the subset of patients with the most advanced form of lung injury.…”