Ultraprotective ventilation allowed by extracorporeal CO2 removal improves the right ventricular function in acute respiratory distress syndrome patients: a quasi-experimental pilot study

Abstract

Background Right ventricular (RV) failure is a common complication in moderate-to-severe acute respiratory distress syndrome (ARDS). RV failure is exacerbated by hypercapnic acidosis and overdistension induced by mechanical ventilation. Veno-venous extracorporeal CO2 removal (ECCO2R) might allow ultraprotective ventilation with lower tidal volume (VT) and plateau pressure (Pplat). This study investigated whether ECCO2R therapy could affect RV function. Methods This was a quasi-experimental prospective observational pilot study performed in a French medical ICU. Patients with moderate-to-severe ARDS with PaO2/FiO2 ratio between 80 and 150 mmHg were enrolled. An ultraprotective ventilation strategy was used with VT at 4 mL/kg of predicted body weight during the 24 h following the start of a low-flow ECCO2R device. RV function was assessed by transthoracic echocardiography (TTE) during the study protocol. Results The efficacy of ECCO2R facilitated an ultraprotective strategy in all 18 patients included. We observed a significant improvement in RV systolic function parameters. Tricuspid annular plane systolic excursion (TAPSE) increased significantly under ultraprotective ventilation compared to baseline (from 22.8 to 25.4 mm; p < 0.05). Systolic excursion velocity (S’ wave) also increased after the 1-day protocol (from 13.8 m/s to 15.1 m/s; p < 0.05). A significant improvement in the aortic velocity time integral (VTIAo) under ultraprotective ventilation settings was observed (p = 0.05). There were no significant differences in the values of systolic pulmonary arterial pressure (sPAP) and RV preload. Conclusion Low-flow ECCO2R facilitates an ultraprotective ventilation strategy thatwould improve RV function in moderate-to-severe ARDS patients. Improvement in RV contractility appears to be mainly due to a decrease in intrathoracic pressure allowed by ultraprotective ventilation, rather than a reduction of PaCO2.

Relationship between echocardiographic tricuspid annular plane systolic excursion and mortality in COVID‐19 patients: A Meta‐analysis

“…Despite also our meta‐regression evidenced that pre‐existing COPD affected the difference in TAPSE between COVID‐19 non‐survivors and survivors analysis, we additionally considered as moderating variables NIV and IMV. Indeed, as previously reported by different analyses, both the type and characteristics of respiratory support may influence the TAPSE estimation 29–31 . Therefore, the high heterogeneity observed in our analysis may be explained by the influence of pre‐existing COPD, the design of reviewed studies and associated inherited bias.…”

“…Indeed, as previously reported by different analyses, both the type and characteristics of respiratory support may influence the TAPSE estimation. [29][30][31] Therefore, the high heterogeneity observed in our analysis may be explained by the influence of pre-existing COPD, the design of reviewed studies and associated inherited bias.…”

Extracorporeal carbon dioxide removal in acute hypoxaemic respiratory failure: a systematic review, Bayesian meta-analysis and trial sequential analysis

“…54 articles were retrieved for full-text review, 21 of which were finally included in the systematic review and meta-analysis. These included three randomised controlled trials [8,17,18], totalling 531 patients, and 18 observational studies [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36], ranging from non-randomised controlled designs to retrospective cohort studies. Most studies were published in the past decade (n=15, 71%) [8,18,[24][25][26][27][28][29][30][31][32][33][34][35][36] and evaluated veno-venous ECCO 2 R (n=12, 57%) [8, 17, 19, 21, 27, 29-33, 35, 36].…”

“…These included three randomised controlled trials [ 8 , 17 , 18 ], totalling 531 patients, and 18 observational studies [ 19 – 36 ], ranging from non-randomised controlled designs to retrospective cohort studies. Most studies were published in the past decade (n=15, 71%) [ 8 , 18 , 24 – 36 ] and evaluated veno-venous ECCO 2 R (n=12, 57%) [ 8 , 17 , 19 , 21 , 27 , 29 – 33 , 35 , 36 ]. Studies were largely undertaken in Europe or North America.…”

The Right Ventricle During Veno-Venous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome: Can We Protect the Injured Ventricle?

“…Use of low flow extracorporeal CO 2 removal in moderate to severe ARDS has been recently shown to improve RV systolic function parameters implying that adequate CO 2 clearance potentially improves pulmonary hemodynamics. 13 Retrospective data (including data from the extracorporeal life support organization registry) has shown that initiation of VV ECMO in ARDS patients requiring vasoactive hemodynamic support resulted in a significant reduction in vasoactive drug doses with a low conversion rate to veno-arterial (VA) ECMO, possibly indicating RV unloading after commencement of VV ECMO. 14,15 The effect of invasive ventilation on pulmonary vascular resistance (PVR) and RV afterload in ARDS patients depends on its net effect on alveolar and extraalveolar vessels.…”