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Bluth T, Güldner A, Spieth PM. [Ventilation concepts under extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS)]. DIE ANAESTHESIOLOGIE 2024; 73:352-362. [PMID: 38625538 DOI: 10.1007/s00101-024-01407-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) is often the last resort for escalation of treatment in patients with severe acute respiratory distress syndrome (ARDS). The success of treatment is mainly determined by patient-specific factors, such as age, comorbidities, duration and invasiveness of the pre-existing ventilation treatment as well as the expertise of the treating ECMO center. In particular, the adjustment of mechanical ventilation during ongoing ECMO treatment remains controversial. Although a reduction of invasiveness of mechanical ventilation seems to be reasonable due to physiological considerations, no improvement in outcome has been demonstrated so far for the use of ultraprotective ventilation regimens.
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Affiliation(s)
- Thomas Bluth
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Andreas Güldner
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Peter M Spieth
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
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2
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Golino G, Forin E, Boni E, Martin M, Perbellini G, Rizzello V, Toniolo A, Danzi V. Secondary pneumomediastinum in COVID-19 patient: A case managed with VV-ECMO. IDCases 2024; 36:e01956. [PMID: 38681081 PMCID: PMC11047182 DOI: 10.1016/j.idcr.2024.e01956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/10/2024] [Accepted: 04/14/2024] [Indexed: 05/01/2024] Open
Abstract
Air leak syndrome, including pneumomediastinum (PM), pneumopericardium, pneumothorax, or subcutaneous emphysema, is primarily caused by chest trauma, cardiothoracic surgery, esophageal perforation, and mechanical ventilation. Secondary pneumomediastinum (SP) is a rare complication, with a much lower incidence reported in patients with coronavirus disease 2019 (COVID-19). Our patient was a 44-year-old nonsmoker male with a previous history of obesity (Body Mass Index [BMI] 35 kg/m2), hyperthyroidism, hypokinetic cardiopathy and atrial fibrillation in treatment with flecainide, who presented to the emergency department with 6 days of fever, cough, dyspnea, and respiratory distress. The COVID-19 diagnosis was confirmed based on a polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). After initiation of mechanical ventilation, a chest computed tomography (CT) on the first day revealed bilateral multifocal ground-glass opacities, consolidation and an extensive SP and pneumoperitoneum. Our therapeutic strategy was initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) as a bridge to recovery after positioning 2 drains (mediastinal and pleural), for both oxygenation and carbon dioxide clearance, to allow protective and ultra-protective ventilation to limit ventilator-induced lung injury (VILI) and the intensity of mechanical power for lung recovery. After another chest CT scan which showed a clear reduction of the PM, 2 pronation and neuromuscular relaxation cycles were also required, with improvement of gas exchange and respiratory mechanics. On the 15th day, lung function recovered and the patient was then weaned from VV-ECMO, and ultimately made a good recovery and was discharged. In conclusion, SP may be a reflection of extensive alveolar damage and should be considered as a potential predictive factor for adverse outcome in critically ill SARS-CoV2 patients.
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Affiliation(s)
- Gianlorenzo Golino
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Edoardo Forin
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Elisa Boni
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Marina Martin
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Guido Perbellini
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Veronica Rizzello
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Anna Toniolo
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Vinicio Danzi
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
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Yehya N, Booth TJ, Ardhanari GD, Thompson JM, Lam LM, Till JE, Mai MV, Keim G, McKeone DJ, Halstead ES, Lahni P, Varisco BM, Zhou W, Carpenter EL, Christie JD, Mangalmurti NS. Inflammatory and tissue injury marker dynamics in pediatric acute respiratory distress syndrome. J Clin Invest 2024; 134:e177896. [PMID: 38573766 PMCID: PMC11093602 DOI: 10.1172/jci177896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/27/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUNDThe molecular signature of pediatric acute respiratory distress syndrome (ARDS) is poorly described, and the degree to which hyperinflammation or specific tissue injury contributes to outcomes is unknown. Therefore, we profiled inflammation and tissue injury dynamics over the first 7 days of ARDS, and associated specific biomarkers with mortality, persistent ARDS, and persistent multiple organ dysfunction syndrome (MODS).METHODSIn a single-center prospective cohort of intubated pediatric patients with ARDS, we collected plasma on days 0, 3, and 7. Nineteen biomarkers reflecting inflammation, tissue injury, and damage-associated molecular patterns (DAMPs) were measured. We assessed the relationship between biomarkers and trajectories with mortality, persistent ARDS, or persistent MODS using multivariable mixed effect models.RESULTSIn 279 patients (64 [23%] nonsurvivors), hyperinflammatory cytokines, tissue injury markers, and DAMPs were higher in nonsurvivors. Survivors and nonsurvivors showed different biomarker trajectories. IL-1α, soluble tumor necrosis factor receptor 1, angiopoietin 2 (ANG2), and surfactant protein D increased in nonsurvivors, while DAMPs remained persistently elevated. ANG2 and procollagen type III N-terminal peptide were associated with persistent ARDS, whereas multiple cytokines, tissue injury markers, and DAMPs were associated with persistent MODS. Corticosteroid use did not impact the association of biomarker levels or trajectory with mortality.CONCLUSIONSPediatric ARDS survivors and nonsurvivors had distinct biomarker trajectories, with cytokines, endothelial and alveolar epithelial injury, and DAMPs elevated in nonsurvivors. Mortality markers overlapped with markers associated with persistent MODS, rather than persistent ARDS.FUNDINGNIH (K23HL-136688, R01-HL148054).
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Affiliation(s)
- Nadir Yehya
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thomas J. Booth
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
| | - Gnana D. Ardhanari
- Division of Pediatric Cardiac Critical Care Medicine, Children’s Heart Institute, Memorial Hermann Hospital, University of Texas Health McGovern Medical School, Houston, Texas, USA
| | - Jill M. Thompson
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
| | - L.K. Metthew Lam
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
| | - Jacob E. Till
- Division of Hematology-Oncology, Department of Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark V. Mai
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta and Emory University, Atlanta, Georgia, USA
| | - Garrett Keim
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel J. McKeone
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and
| | - E. Scott Halstead
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Patrick Lahni
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Brian M. Varisco
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Research Institute, Little Rock, Arkansas, USA
| | - Wanding Zhou
- Center for Computational and Genomic Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Erica L. Carpenter
- Division of Hematology-Oncology, Department of Medicine, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
- Center for Translational Lung Biology and
- Center for Clinical Epidemiology and Biostatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nilam S. Mangalmurti
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Department of Medicine and
- Center for Translational Lung Biology and
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Le Pape S, Joly F, Arrivé F, Frat JP, Rodriguez M, Joos M, Marchasson L, Wairy M, Thille AW, Coudroy R. Factors associated with decreased compliance after on-site extracorporeal membrane oxygenation cannulation for acute respiratory distress syndrome: A retrospective, observational cohort study. JOURNAL OF INTENSIVE MEDICINE 2024; 4:194-201. [PMID: 38681786 PMCID: PMC11043634 DOI: 10.1016/j.jointm.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/11/2023] [Accepted: 09/26/2023] [Indexed: 05/01/2024]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) is systematically associated with decreased respiratory system compliance (CRS). It remains unclear whether transportation to the referral ECMO center, changes in ventilatory mode or settings to achieve ultra-protective ventilation, or the natural evolution of ARDS drives this change in respiratory mechanics. Herein, we assessed the precise moment when CRS decreases after ECMO cannulation and identified factors associated with decreased CRS. Methods To rule out the effect of transportation and the different modes of ventilation on CRS, we conducted a retrospective, single-center, observational cohort study from January 2013 to May 2020, on 22 patients with severe ARDS requiring on-site ECMO and ventilated in pressure-controlled mode to achieve ultra-protective ventilation. CRS was assessed at different time points ranging from 12 h before ECMO cannulation to 72 h after ECMO cannulation. The primary outcome was the relative change in CRS between 3 h before and 3 h after ECMO cannulation. The secondary outcomes included variables associated with the relative changes in CRS within the first 3 h after ECMO cannulation and the relative changes in CRS at each time point. Results CRS decreased within the first 3 h after ECMO cannulation (-28.3%, 95% confidence interval [CI]: -38.8 to -17.9, P<0.001), while the decrease was mild before and after these first 3 h after ECMO cannulation. To achieve ultra-protective ventilation, respiratory rate decreased in the mean by -13 breaths/min (95% CI: -15 to -11) and driving pressure by -8.3 cmH2O (95% CI: -11.2 to -5.3), resulting in decreased tidal volume by -3.3 mL/kg of predicted body weight (95% CI: -3.9 to -2.6) as compared to before ECMO cannulation (P <0.001 for all). Plateau pressure reduction, driving pressure reduction, and tidal volume reduction were significantly associated with decreased CRS after ECMO cannulation, whereas neither respiratory rate, positive end-expiratory pressure, inspired fraction of oxygen, fluid balance, nor mean airway pressure was associated with decreased CRS. Conclusions Decreased driving pressure resulting in lower tidal volume to achieve ultra-protective ventilation after ECMO cannulation was associated with a marked decrease in CRS in ARDS patients with on-site ECMO cannulation.
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Affiliation(s)
- Sylvain Le Pape
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Florent Joly
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - François Arrivé
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Jean-Pierre Frat
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Maeva Rodriguez
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Maïa Joos
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Laura Marchasson
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Mathilde Wairy
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Arnaud W. Thille
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Rémi Coudroy
- Centre Hospitalier Universitaire de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
- INSERM Centre d'Investigation Clinique 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
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Zaidi SF, Shaikh A, Khan DA, Surani S, Ratnani I. Driving pressure in mechanical ventilation: A review. World J Crit Care Med 2024; 13:88385. [PMID: 38633474 PMCID: PMC11019631 DOI: 10.5492/wjccm.v13.i1.88385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 12/04/2023] [Accepted: 01/05/2024] [Indexed: 03/05/2024] Open
Abstract
Driving pressure (∆P) is a core therapeutic component of mechanical ventilation (MV). Varying levels of ∆P have been employed during MV depending on the type of underlying pathology and severity of injury. However, ∆P levels have also been shown to closely impact hard endpoints such as mortality. Considering this, conducting an in-depth review of ∆P as a unique, outcome-impacting therapeutic modality is extremely important. There is a need to understand the subtleties involved in making sure ∆P levels are optimized to enhance outcomes and minimize harm. We performed this narrative review to further explore the various uses of ∆P, the different parameters that can affect its use, and how outcomes vary in different patient populations at different pressure levels. To better utilize ∆P in MV-requiring patients, additional large-scale clinical studies are needed.
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Affiliation(s)
- Syeda Farheen Zaidi
- Department of Medicine, Queen Mary University, London E1 4NS, United Kingdom
| | - Asim Shaikh
- Department of Medicine, Aga Khan University, Sindh, Karachi 74500, Pakistan
| | - Daniyal Aziz Khan
- Department of Medicine, Jinnah Postgraduate Medical Center, Sindh, Karachi 75510, Pakistan
| | - Salim Surani
- Department of Medicine and Pharmacology, Texas A and M University, College Station, TX 77843, United States
| | - Iqbal Ratnani
- Department of Anesthesiology and Critical Care, Houston Methodist Hospital, Houston, TX 77030, United States
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Deniel G, Dhelft F, Lancelot S, Orkisz M, Roux E, Mouton W, Benzerdjeb N, Richard JC, Bitker L. Pulmonary inflammation decreases with ultra-protective ventilation in experimental ARDS under VV-ECMO: a positron emission tomography study. Front Med (Lausanne) 2024; 11:1338602. [PMID: 38444415 PMCID: PMC10912585 DOI: 10.3389/fmed.2024.1338602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024] Open
Abstract
Background Experimentally, ultra-protective ventilation (UPV, tidal volumes [VT] < 4 mL.kg-1) strategies in conjunction with veno-venous extracorporeal membrane oxygenation (VV-ECMO) are associated with lesser ventilator-induced lung injuries (VILI) during acute respiratory distress syndrome (ARDS). However, whether these strategies reduce lung inflammation more effectively than protective ventilation (PV) remains unclear. We aimed to demonstrate that a UPV strategy decreases acute lung inflammation in comparison with PV in an experimental swine model of ARDS. Methods ARDS was induced by tracheal instillation of chlorhydric acid in sedated and paralyzed animals under mechanical ventilation. Animals were randomized to receive either UPV (VT 1 mL.kg-1, positive end-expiration pressure [PEEP] set to obtain plateau pressure between 20 and 25 cmH2O and respiratory rate [RR] at 5 min-1 under VV-ECMO) or PV (VT 6 mL.kg-1, PEEP set to obtain plateau pressure between 28 and 30 cmH2O and RR at 25 min-1) during 4 h. After 4 h, a positron emission tomography with [11C](R)-PK11195 (ligand to TSPO-bearing macrophages) injection was realized, coupled with quantitative computerized tomography (CT). Pharmacokinetic multicompartment models were used to quantify regional [11C](R)-PK11195 lung uptake. [11C](R)-PK11195 lung uptake and CT-derived respiratory variables were studied regionally across eight lung regions distributed along the antero-posterior axis. Results Five pigs were randomized to each study group. Arterial O2 partial pressure to inspired O2 fraction were not significantly different between study groups after experimental ARDS induction (75 [68-80] mmHg in a PV group vs. 87 [69-133] mmHg in a UPV group, p = 0.20). Compared to PV animals, UPV animals exhibited a significant decrease in the regional non-aerated compartment in the posterior lung levels, in mechanical power, and in regional dynamic strain and no statistical difference in tidal hyperinflation after 4 h. UPV animals had a significantly lower [11C](R)-PK11195 uptake, compared to PV animals (non-displaceable binding potential 0.35 [IQR, 0.20-0.59] in UPV animals and 1.01 [IQR, 0.75-1.59] in PV animals, p = 0.01). Regional [11C](R)-PK11195 uptake was independently associated with the interaction of regional tidal hyperinflation and regional lung compliance. Conclusion In an experimental model of ARDS, 4 h of UPV strategy significantly decreased lung inflammation, in relation to the control of VT-derived determinants of VILI.
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Affiliation(s)
- Guillaume Deniel
- Service de Médecine Intensive-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Univ Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, Inserm, CREATIS UMR, Villeurbanne, France
| | - François Dhelft
- Service de Médecine Intensive-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Université de Lyon, Université LYON 1, Lyon, France
| | - Sophie Lancelot
- Université de Lyon, Université LYON 1, Lyon, France
- CERMEP – Imagerie du Vivant, Lyon, France
- Hospices Civils de Lyon, Lyon, France
| | - Maciej Orkisz
- Univ Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, Inserm, CREATIS UMR, Villeurbanne, France
| | - Emmanuel Roux
- Univ Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, Inserm, CREATIS UMR, Villeurbanne, France
| | - William Mouton
- Laboratoire Commun de Recherche Hospices Civils de Lyon/bioMérieux, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Nazim Benzerdjeb
- Université de Lyon, Université LYON 1, Lyon, France
- Centre d’Anatomie et Cytologie Pathologique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Jean-Christophe Richard
- Service de Médecine Intensive-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Univ Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, Inserm, CREATIS UMR, Villeurbanne, France
- Université de Lyon, Université LYON 1, Lyon, France
| | - Laurent Bitker
- Service de Médecine Intensive-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Univ Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, Inserm, CREATIS UMR, Villeurbanne, France
- Université de Lyon, Université LYON 1, Lyon, France
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Boesing C, Schaefer L, Graf PT, Pelosi P, Rocco PRM, Luecke T, Krebs J. Effects of different positive end-expiratory pressure titration strategies on mechanical power during ultraprotective ventilation in ARDS patients treated with veno-venous extracorporeal membrane oxygenation: A prospective interventional study. J Crit Care 2024; 79:154406. [PMID: 37690365 DOI: 10.1016/j.jcrc.2023.154406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 05/13/2023] [Accepted: 07/09/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Ultraprotective ventilation in acute respiratory distress syndrome (ARDS) patients with veno-venous extracorporeal membrane oxygenation (VV ECMO) reduces mechanical power (MP) through changes in positive end-expiratory pressure (PEEP); however, the optimal approach to titrate PEEP is unknown. This study assesses the effects of three PEEP titration strategies on MP, hemodynamic parameters, and oxygen delivery in twenty ARDS patients with VV ECMO. MATERIAL AND METHODS PEEP was titrated according to: (A) a PEEP of 10 cmH2O representing the lowest recommendation by the Extracorporeal Life Support Organization (PEEPELSO), (B) the highest static compliance of the respiratory system (PEEPCstat,RS), and (C) a target end-expiratory transpulmonary pressure of 0 cmH2O (PEEPPtpexp). RESULTS PEEPELSO was lower compared to PEEPCstat,RS and PEEPPtpexp (10.0 ± 0.0 vs. 16.2 ± 4.7 cmH2O and 17.3 ± 4.0 cmH2O, p < 0.001 each, respectively). PEEPELSO reduced MP compared to PEEPCstat,RS and PEEPPtpexp (5.3 ± 1.3 vs. 6.8 ± 2.0 and 6.9 ± 2.3 J/min, p < 0.001 each, respectively). PEEPELSO resulted in less lung stress compared to PEEPCstat,RS (p = 0.011) and PEEPPtpexp (p < 0.001) and increased cardiac output and oxygen delivery (p < 0.001 each). CONCLUSIONS An empirical PEEP of 10 cmH2O minimized MP, provided favorable hemodynamics, and increased oxygen delivery in ARDS patients treated with VV ECMO. TRIAL REGISTRATION German Clinical Trials Register (DRKS00013967). Registered 02/09/2018https://drks.de/search/en/trial/DRKS00013967.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Laura Schaefer
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Peter T Graf
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesiology and Critical Care - San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, Rio de Janeiro, Brazil.
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
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8
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Zhou Y, Wang X, Du W, He H, Wang X, Cui N, Long Y. The level of partial pressure of carbon dioxide affects respiratory effort in COVID-19 patients undergoing pressure support ventilation with extracorporeal membrane oxygenation. BMC Anesthesiol 2024; 24:23. [PMID: 38216876 PMCID: PMC10785506 DOI: 10.1186/s12871-023-02382-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 12/12/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Patients with COVID-19 undergoing pressure support ventilation (PSV) with extracorporeal membrane oxygenation (ECMO) commonly had high respiratory drive, which could cause self-inflicted lung injury. The aim of this study was to evaluate the influence of different levels of partial pressure of carbon dioxide(PaCO2) on respiratory effort in COVID-19 patients undergoing PSV with ECMO. METHODS ECMO gas flow was downregulated from baseline (respiratory rate < 25 bpm, peak airway pressure < 25 cm H2O, tidal volume < 6 mL/kg, PaCO2 < 40 mmHg) until PaCO2 increased by 5 - 10 mmHg. The pressure muscle index (PMI) and airway pressure swing during occlusion (ΔPOCC) were used to monitor respiratory effort, and they were measured before and after enforcement of the regulations. RESULTS Ten patients with COVID-19 who had undergone ECMO were enrolled in this prospective study. When the PaCO2 increased from 36 (36 - 37) to 42 (41-43) mmHg (p = 0.0020), there was a significant increase in ΔPOCC [from 5.6 (4.7-8.0) to 11.1 (8.5-13.1) cm H2O, p = 0.0020] and PMI [from 3.0 ± 1.4 to 6.5 ± 2.1 cm H2O, p < 0.0001]. Meanwhile, increased inspiratory effort determined by elevated PaCO2 levels led to enhancement of tidal volume from 4.1 ± 1.2 mL/kg to 5.3 ± 1.5 mL/kg (p = 0.0003) and respiratory rate from 13 ± 2 to 15 ± 2 bpm (p = 0.0266). In addition, the increase in PaCO2 was linearly correlated with changes in ΔPOCC and PMI (R2 = 0.7293, p = 0.0003 and R2 = 0.4105, p = 0.0460, respectively). CONCLUSIONS In patients with COVID-19 undergoing PSV with ECMO, an increase of PaCO2 could increase the inspiratory effort.
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Affiliation(s)
- Yuankai Zhou
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xinchen Wang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Wei Du
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Na Cui
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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9
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Collins PD, Giosa L, Camporota L, Barrett NA. State of the art: Monitoring of the respiratory system during veno-venous extracorporeal membrane oxygenation. Perfusion 2024; 39:7-30. [PMID: 38131204 DOI: 10.1177/02676591231210461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Monitoring the patient receiving veno-venous extracorporeal membrane oxygenation (VV ECMO) is challenging due to the complex physiological interplay between native and membrane lung. Understanding these interactions is essential to understand the utility and limitations of different approaches to respiratory monitoring during ECMO. We present a summary of the underlying physiology of native and membrane lung gas exchange and describe different tools for titrating and monitoring gas exchange during ECMO. However, the most important role of VV ECMO in severe respiratory failure is as a means of avoiding further ergotrauma. Although optimal respiratory management during ECMO has not been defined, over the last decade there have been advances in multimodal respiratory assessment which have the potential to guide care. We describe a combination of imaging, ventilator-derived or invasive lung mechanic assessments as a means to individualise management during ECMO.
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Affiliation(s)
- Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Luigi Camporota
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Nicholas A Barrett
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
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10
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Gannon WD, Teijeiro-Paradis R, Prekker ME, Pratt EH, Tucker WD, Casey JD. Climbing the Evidence Pyramid: Developing an Evidence-Based Approach to the Provision of Venovenous Extracorporeal Membrane Oxygenation. Crit Care Med 2023; 51:1830-1834. [PMID: 37971340 DOI: 10.1097/ccm.0000000000006037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Whitney D Gannon
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Matthew E Prekker
- Department of Emergency Medicine and Pulmonary/Critical Care Medicine, Hennepin County Medical Center, Minneapolis MN
| | - Elias H Pratt
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC
| | - William D Tucker
- Division of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan D Casey
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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11
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Orthmann T, Ltaief Z, Bonnemain J, Kirsch M, Piquilloud L, Liaudet L. Retrospective analysis of factors associated with outcome in veno-venous extra-corporeal membrane oxygenation. BMC Pulm Med 2023; 23:301. [PMID: 37587413 PMCID: PMC10429070 DOI: 10.1186/s12890-023-02591-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/31/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND The outcome of Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) in acute respiratory failure may be influenced by patient-related factors, center expertise and modalities of mechanical ventilation (MV) during ECMO. We determined, in a medium-size ECMO center in Switzerland, possible factors associated with mortality during VV-ECMO for acute respiratory failure of various etiologies. METHODS We retrospectively analyzed all patients treated with VV-ECMO in our University Hospital from 2012 to 2019 (pre-COVID era). Demographic variables, severity scores, MV duration before ECMO, pre and on-ECMO arterial blood gases and respiratory variables were collected. The primary outcome was ICU mortality. Data were compared between survivors and non-survivors, and factors associated with mortality were assessed in univariate and multivariate analyses. RESULTS Fifty-one patients (33 ARDS, 18 non-ARDS) were included. ICU survival was 49% (ARDS, 39%; non-ARDS 67%). In univariate analyses, a higher driving pressure (DP) at 24h and 48h on ECMO (whole population), longer MV duration before ECMO and higher DP at 24h on ECMO (ARDS patients), were associated with mortality. In multivariate analyses, ECMO indication, higher DP at 24h on ECMO and, in ARDS, longer MV duration before ECMO, were independently associated with mortality. CONCLUSIONS DP on ECMO and longer MV duration before ECMO (in ARDS) are major, and potentially modifiable, factors influencing outcome during VV-ECMO.
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Affiliation(s)
- Thomas Orthmann
- The Department of Adult Intensive Care Medicine, University Hospital Medical Center, Lausanne, 1011, Switzerland
- The Faculty of Biology and Medicine, University of Lausanne, Lausanne, 1011, Switzerland
| | - Zied Ltaief
- The Department of Adult Intensive Care Medicine, University Hospital Medical Center, Lausanne, 1011, Switzerland
| | - Jean Bonnemain
- The Department of Adult Intensive Care Medicine, University Hospital Medical Center, Lausanne, 1011, Switzerland
| | - Matthias Kirsch
- The Faculty of Biology and Medicine, University of Lausanne, Lausanne, 1011, Switzerland
- The Department of Cardiac Surgery, University Hospital Medical Center, Lausanne, 1011, Switzerland
| | - Lise Piquilloud
- The Department of Adult Intensive Care Medicine, University Hospital Medical Center, Lausanne, 1011, Switzerland
- The Faculty of Biology and Medicine, University of Lausanne, Lausanne, 1011, Switzerland
| | - Lucas Liaudet
- The Department of Adult Intensive Care Medicine, University Hospital Medical Center, Lausanne, 1011, Switzerland.
- The Faculty of Biology and Medicine, University of Lausanne, Lausanne, 1011, Switzerland.
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12
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Grotberg JC, Reynolds D, Kraft BD. Management of severe acute respiratory distress syndrome: a primer. Crit Care 2023; 27:289. [PMID: 37464381 DOI: 10.1186/s13054-023-04572-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023] Open
Abstract
This narrative review explores the physiology and evidence-based management of patients with severe acute respiratory distress syndrome (ARDS) and refractory hypoxemia, with a focus on mechanical ventilation, adjunctive therapies, and veno-venous extracorporeal membrane oxygenation (V-V ECMO). Severe ARDS cases increased dramatically worldwide during the Covid-19 pandemic and carry a high mortality. The mainstay of treatment to improve survival and ventilator-free days is proning, conservative fluid management, and lung protective ventilation. Ventilator settings should be individualized when possible to improve patient-ventilator synchrony and reduce ventilator-induced lung injury (VILI). Positive end-expiratory pressure can be individualized by titrating to best respiratory system compliance, or by using advanced methods, such as electrical impedance tomography or esophageal manometry. Adjustments to mitigate high driving pressure and mechanical power, two possible drivers of VILI, may be further beneficial. In patients with refractory hypoxemia, salvage modes of ventilation such as high frequency oscillatory ventilation and airway pressure release ventilation are additional options that may be appropriate in select patients. Adjunctive therapies also may be applied judiciously, such as recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, or glucocorticoids, and may improve oxygenation, but do not clearly reduce mortality. In select, refractory cases, the addition of V-V ECMO improves gas exchange and modestly improves survival by allowing for lung rest. In addition to VILI, patients with severe ARDS are at risk for complications including acute cor pulmonale, physical debility, and neurocognitive deficits. Even among the most severe cases, ARDS is a heterogeneous disease, and future studies are needed to identify ARDS subgroups to individualize therapies and advance care.
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Affiliation(s)
- John C Grotberg
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA.
| | - Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
| | - Bryan D Kraft
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, 63110, USA
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13
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Valentin S, Amalric M, Granier G, Pequignot B, Guervilly C, Duarte K, Girerd N, Levy B, Dunand P, Koszutski M, Roze H, Kimmoun A. Prognostic value of respiratory compliance course on mortality in COVID-19 patients with vv-ECMO. Ann Intensive Care 2023; 13:54. [PMID: 37341800 DOI: 10.1186/s13613-023-01152-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/09/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND COVID-19-associated acute respiratory distress syndrome (ARDS) supported by veno-venous extra-corporal membrane oxygenation (vv-ECMO) results in a high in-hospital mortality rate of more than 35%. However, after cannulation, no prognostic factor has been described to guide the management of these patients. The objective was to assess the association between static respiratory compliance over the first 10 days post-vv-ECMO implantation on 180-day mortality. RESULTS In this multicentric retrospective study in three ECMO referral centers, all patients with COVID-19-associated ARDS supported by vv-ECMO were included from 03/01/2020 to 12/31/2021. Patients were ventilated with ultra-protective settings targeting a driving pressure lower than 15 cmH2O. 122 patients were included. Median age was 59 IQR (52-64), 83 (68%) were male, with a median body mass index of 33 (28-37) kg/m2. Delay between first symptoms to vv-ECMO implantation was 16 (10-21) days. Six-month death was 48%. Over the first ten days, compliance increased in 180 day survivors [from 18 (12-25) to 20 (15-27) mL/cmH2O] compared to non-survivors [from 12 (9-20) to 10 (8-14) mL/cmH2O, p interaction < 0.0001]. A time varying multivariable Cox model found age, history of chronic lung disease, compliance from day one to day ten and sweep gas flow from day one to day ten as independent factors associated with 180-day mortality. CONCLUSIONS In COVID-19-associated ARDS, static respiratory compliance course over the first ten days post-vv-ECMO implantation is associated with 180-day mortality. This new information may provide crucial information on the patient's prognosis for intensivists.
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Affiliation(s)
- Simon Valentin
- CHRU de Nancy, Médecine Intensive et Réanimation Brabois, Université de Lorraine, Nancy, France
- CHRU de Nancy, Pôle des Spécialités Médicales/Département de Pneumologie, Université de Lorraine, Nancy, France
- INSERM U1254 IADI, Université de Lorraine, Nancy, France
| | - Mathieu Amalric
- Médecine Intensive et Réanimation, Hôpital Nord, Assistance Publique - Hôpitaux de Marseille, Marseille, France
- Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Guillaume Granier
- CHRU de Nancy, Médecine Intensive et Réanimation Brabois, Université de Lorraine, Nancy, France
| | - Benjamin Pequignot
- CHRU de Nancy, Médecine Intensive et Réanimation Brabois, Université de Lorraine, Nancy, France
- INSERM U1116, Université de Lorraine, Nancy, France
| | - Christophe Guervilly
- Médecine Intensive et Réanimation, Hôpital Nord, Assistance Publique - Hôpitaux de Marseille, Marseille, France
- Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Kevin Duarte
- INSERM 1433 CIC-P CHRU de Nancy, FCRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Nicolas Girerd
- INSERM 1433 CIC-P CHRU de Nancy, FCRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Bruno Levy
- CHRU de Nancy, Médecine Intensive et Réanimation Brabois, Université de Lorraine, Nancy, France
- INSERM U1116, Université de Lorraine, Nancy, France
| | - Paul Dunand
- CHRU de Nancy, Médecine Intensive et Réanimation Brabois, Université de Lorraine, Nancy, France
| | - Matthieu Koszutski
- CHRU de Nancy, Médecine Intensive et Réanimation Brabois, Université de Lorraine, Nancy, France
| | - Hadrien Roze
- Département d'anesthésie Réanimation Sud, Centre Médico-Chirurgical Magellan, Hôpital, Haut Leveque Hospital, Université de Bordeaux, Pessac, France
- INSERM 1045, Centre de Recherche Cardio Thoracique, Pessac, France
| | - Antoine Kimmoun
- CHRU de Nancy, Médecine Intensive et Réanimation Brabois, Université de Lorraine, Nancy, France.
- INSERM U1116, Université de Lorraine, Nancy, France.
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14
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Kormish J, Ghuman T, Liu RY, Srinathan SK, Tan L, Graham K, Enns S, Buduhan G, Halayko AJ, Pascoe CD, Kidane B. Temporal and Spatial Patterns of Inflammation and Tissue Injury in Patients with Postoperative Respiratory Failure after Lung Resection Surgery: A Nested Case-Control Study. Int J Mol Sci 2023; 24:10051. [PMID: 37373199 DOI: 10.3390/ijms241210051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/06/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023] Open
Abstract
Thoracic surgeries involving resection of lung tissue pose a risk of severe postoperative pulmonary complications, including acute respiratory distress syndrome (ARDS) and respiratory failure. Lung resections require one-lung ventilation (OLV) and, thus, are at higher risk of ventilator-induced lung injury (VILI) attributable to barotrauma and volutrauma in the one ventilated lung, as well as hypoxemia and reperfusion injury on the operated lung. Further, we also aimed to assess the differences in localized and systemic markers of tissue injury/inflammation in those who developed respiratory failure after lung surgery versus matched controls who did not develop respiratory failure. We aimed to assess the different inflammatory/injury marker patterns induced in the operated and ventilated lung and how this compared to the systemic circulating inflammatory/injury marker pattern. A case-control study nested within a prospective cohort study was performed. Patients with postoperative respiratory failure after lung surgery (n = 5) were matched with control patients (n = 6) who did not develop postoperative respiratory failure. Biospecimens (arterial plasma, bronchoalveolar lavage separately from ventilated and operated lungs) were obtained from patients undergoing lung surgery at two timepoints: (1) just prior to initiation of OLV and (2) after lung resection was completed and OLV stopped. Multiplex electrochemiluminescent immunoassays were performed for these biospecimen. We quantified 50 protein biomarkers of inflammation and tissue injury and identified significant differences between those who did and did not develop postoperative respiratory failure. The three biospecimen types also display unique biomarker patterns.
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Affiliation(s)
- Jay Kormish
- Section of Thoracic Surgery, Department of Surgery, Health Sciences Centre, Winnipeg, MB R3A 1R9, Canada
- Department of Surgery, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Tejas Ghuman
- Department of Surgery, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
- Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Richard Y Liu
- Section of Thoracic Surgery, Department of Surgery, Health Sciences Centre, Winnipeg, MB R3A 1R9, Canada
- Department of Surgery, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Sadeesh K Srinathan
- Section of Thoracic Surgery, Department of Surgery, Health Sciences Centre, Winnipeg, MB R3A 1R9, Canada
- Department of Surgery, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Lawrence Tan
- Department of Surgery, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Kristen Graham
- Section of Thoracic Surgery, Department of Surgery, Health Sciences Centre, Winnipeg, MB R3A 1R9, Canada
| | - Stephanie Enns
- Section of Thoracic Surgery, Department of Surgery, Health Sciences Centre, Winnipeg, MB R3A 1R9, Canada
| | - Gordon Buduhan
- Section of Thoracic Surgery, Department of Surgery, Health Sciences Centre, Winnipeg, MB R3A 1R9, Canada
- Department of Surgery, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Andrew J Halayko
- Children's Hospital Research Institute of Manitoba, Winnipeg, MB R3A 1R9, Canada
- Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Christopher D Pascoe
- Children's Hospital Research Institute of Manitoba, Winnipeg, MB R3A 1R9, Canada
- Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Biniam Kidane
- Section of Thoracic Surgery, Department of Surgery, Health Sciences Centre, Winnipeg, MB R3A 1R9, Canada
- Department of Surgery, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, MB R3A 1R9, Canada
- Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
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15
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Masi P, Bagate F, Tuffet S, Piscitelli M, Folliguet T, Razazi K, De Prost N, Carteaux G, Mekontso Dessap A. Dual titration of minute ventilation and sweep gas flow to control carbon dioxide variations in patients on venovenous extracorporeal membrane oxygenation. Ann Intensive Care 2023; 13:45. [PMID: 37225933 DOI: 10.1186/s13613-023-01138-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND The implantation of venovenous extracorporeal membrane oxygenation (VV-ECMO) support to manage severe acute respiratory distress syndrome generates large variations in carbon dioxide partial pressure (PaCO2) that are associated with intracranial bleeding. We assessed the feasibility and efficacy of a pragmatic protocol for progressive dual titration of sweep gas flow and minute ventilation after VV-ECMO implantation in order to limit significant PaCO2 variations. PATIENTS AND METHODS A protocol for dual titration of sweep gas flow and minute ventilation following VV-ECMO implantation was implemented in our unit in September 2020. In this single-centre retrospective before-after study, we included patients who required VV-ECMO from March, 2020 to May, 2021, which corresponds to two time periods: from March to August, 2020 (control group) and from September, 2020 to May, 2021 (protocol group). The primary endpoint was the mean absolute change in PaCO2 in consecutive arterial blood gases samples drawn over the first 12 h following VV-ECMO implantation. Secondary endpoints included large (> 25 mmHg) initial variations in PaCO2, intracranial bleedings and mortality in both groups. RESULTS Fifty-one patients required VV-ECMO in our unit during the study period, including 24 in the control group and 27 in the protocol group. The protocol was proved feasible. The 12-h mean absolute change in PaCO2 was significantly lower in patients of the protocol group as compared with their counterparts (7 mmHg [6-12] vs. 12 mmHg [6-24], p = 0.007). Patients of the protocol group experienced less large initial variations in PaCO2 immediately after ECMO implantation (7% vs. 29%, p = 0.04) and less intracranial bleeding (4% vs. 25%, p = 0.04). Mortality was similar in both groups (35% vs. 46%, p = 0.42). CONCLUSION Implementation of our protocol for dual titration of minute ventilation and sweep gas flow was feasible and associated with less initial PaCO2 variation than usual care. It was also associated with less intracranial bleeding.
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Affiliation(s)
- Paul Masi
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France.
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France.
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France.
| | - François Bagate
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Samuel Tuffet
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Mariantonietta Piscitelli
- Service de chirurgie cardiaque, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Université Paris Est Créteil, Faculté de Santé, F-94010, Créteil, France
| | - Thierry Folliguet
- Service de chirurgie cardiaque, DMU CARE, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Université Paris Est Créteil, Faculté de Santé, F-94010, Créteil, France
| | - Keyvan Razazi
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Nicolas De Prost
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri-Mondor, 94010, Créteil, France
- CARMAS, Univ Paris Est Créteil, 94010, Créteil, France
- IMRB, Univ Paris Est Créteil, INSERM, 94010, Créteil, France
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16
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Wu HP, Leu SW, Lin SW, Hung CY, Chen NH, Hu HC, Huang CC, Kao KC. Role of Changes in Driving Pressure and Mechanical Power in Predicting Mortality in Patients with Acute Respiratory Distress Syndrome. Diagnostics (Basel) 2023; 13:diagnostics13071226. [PMID: 37046444 PMCID: PMC10093066 DOI: 10.3390/diagnostics13071226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
Driving pressure (ΔP) and mechanical power (MP) are associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). We aimed to investigate which was better to predict mortality between changes in ΔP and MP. We reanalyzed data from a prospective observational cohort study of patients with ARDS in our hospital. Serial ΔP and MP values were calculated. The factors associated with survival were analyzed. Binary logistic regression showed that age (odds ratio (OR), 1.012; 95% confidence interval (CI), 1.003-1.022), Sequential Organ Failure assessment (SOFA) score (OR, 1.144; 95% CI, 1.086-1.206), trauma (OR, 0.172; 95% CI, 0.035-0.838), ΔP (OR, 1.077; 95% CI, 1.044-1.111), change in ΔP (OR, 1.087; 95% CI, 1.054-1.120), and change in MP (OR, 1.018; 95% CI, 1.006-1.029) were independently associated with 30-day mortality. Change in MP, change in ΔP, and SOFA scores were superior to ΔP in terms of the accuracy of predicting 30-day mortality. In conclusion, calculating change in ΔP is easy for respiratory therapists in clinical practice and may be used to predict mortality in patients with ARDS.
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Affiliation(s)
- Huang-Pin Wu
- Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung 204, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Shaw-Woei Leu
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Shih-Wei Lin
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chen-Yiu Hung
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Ning-Hung Chen
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Han-Chung Hu
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Chung-Chi Huang
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Kuo-Chin Kao
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
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17
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Assouline B, Combes A, Schmidt M. Setting and Monitoring of Mechanical Ventilation During Venovenous ECMO. Crit Care 2023; 27:95. [PMID: 36941722 PMCID: PMC10027594 DOI: 10.1186/s13054-023-04372-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
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 .
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Affiliation(s)
- Benjamin Assouline
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alain Combes
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.
- Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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Odish M, Pollema T, Meier A, Hepokoski M, Yi C, Spragg R, Patel HH, Alexander LEC, Sun XS, Jain S, Simonson TS, Malhotra A, Owens RL. Very Low Driving-Pressure Ventilation in Patients With COVID-19 Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation: A Physiologic Study. J Cardiothorac Vasc Anesth 2023; 37:423-431. [PMID: 36567221 PMCID: PMC9701579 DOI: 10.1053/j.jvca.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/01/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine in patients with acute respiratory distress syndrome (ARDS) on venovenous extracorporeal membrane oxygenation (VV ECMO) whether reducing driving pressure (ΔP) would decrease plasma biomarkers of inflammation and lung injury (interleukin-6 [IL-6], IL-8, and the soluble receptor for advanced glycation end-products sRAGE). DESIGN A single-center prospective physiologic study. SETTING At a single university medical center. PARTICIPANTS Adult patients with severe COVID-19 ARDS on VV ECMO. INTERVENTIONS Participants on VV ECMO had the following biomarkers measured: (1) pre-ECMO with low-tidal-volume ventilation (LTVV), (2) post-ECMO with LTVV, (3) during low-driving-pressure ventilation (LDPV), (4) after 2 hours of very low driving-pressure ventilation (V-LDPV, main intervention ΔP = 1 cmH2O), and (5) 2 hours after returning to LDPV. MAIN MEASUREMENTS AND RESULTS Twenty-six participants were enrolled; 21 underwent V-LDPV. There was no significant change in IL-6, IL-8, and sRAGE from LDPV to V-LDPV and from V-LDPV to LDPV. Only participants (9 of 21) with nonspontaneous breaths had significant change (p < 0.001) in their tidal volumes (Vt) (mean ± SD), 1.9 ± 0.5, 0.1 ± 0.2, and 2.0 ± 0.7 mL/kg predicted body weight (PBW). Participants with spontaneous breathing, Vt were unchanged-4.5 ± 3.1, 4.7 ± 3.1, and 5.6 ± 2.9 mL/kg PBW (p = 0.481 and p = 0.065, respectively). There was no relationship found when accounting for Vt changes and biomarkers. CONCLUSIONS Biomarkers did not significantly change with decreased ΔPs or Vt changes during the first 24 hours post-ECMO. Despite deep sedation, reductions in Vt during V-LDPV were not reliably achieved due to spontaneous breaths. Thus, patients on VV ECMO for ARDS may have higher Vt (ie, transpulmonary pressure) than desired despite low ΔPs or Vt.
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Affiliation(s)
- Mazen Odish
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA.
| | - Travis Pollema
- UC San Diego Department of Surgery, Division of Cardiovascular and Thoracic Surgery, La Jolla, CA
| | - Angela Meier
- UC San Diego Department of Anesthesiology, Division of Critical Care, La Jolla, CA
| | - Mark Hepokoski
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA; VA San Diego Healthcare System, Pulmonary Critical Care Section, San Diego, CA
| | - Cassia Yi
- UC San Diego Health Department of Nursing, La Jolla, CA
| | - Roger Spragg
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA
| | - Hemal H Patel
- UC San Diego Department of Anesthesiology, Division of Critical Care, La Jolla, CA; VA San Diego Healthcare System, Pulmonary Critical Care Section, San Diego, CA
| | - Laura E Crotty Alexander
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA; VA San Diego Healthcare System, Pulmonary Critical Care Section, San Diego, CA
| | - Xiaoying Shelly Sun
- UC San Diego, Herbert Wertheim School of Public Health and Human Longevity Science, La Jolla, CA
| | - Sonia Jain
- UC San Diego, Herbert Wertheim School of Public Health and Human Longevity Science, La Jolla, CA
| | - Tatum S Simonson
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA
| | - Atul Malhotra
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA
| | - Robert L Owens
- UC San Diego Department of Medicine, Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, La Jolla, CA
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19
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Collins PD, Giosa L, Camarda V, Camporota L. Physiological adaptations during weaning from veno-venous extracorporeal membrane oxygenation. Intensive Care Med Exp 2023; 11:7. [PMID: 36759388 PMCID: PMC9911184 DOI: 10.1186/s40635-023-00493-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/18/2023] [Indexed: 02/11/2023] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) has an established evidence base in acute respiratory distress syndrome (ARDS) and has seen exponential growth in its use over the past decades. However, there is a paucity of evidence regarding the approach to weaning, with variation of practice and outcomes between centres. Preconditions for weaning, management of patients' sedation and mechanical ventilation during this phase, criteria defining success or failure, and the optimal duration of a trial prior to decannulation are all debated subjects. Moreover, there is no prospective evidence demonstrating the superiority of weaning the sweep gas flow (SGF), the extracorporeal blood flow (ECBF) or the fraction of oxygen of the SGF (FdO2), thereby a broad inter-centre variability exists in this regard. Accordingly, the aim of this review is to discuss the required physiological basis to interpret different weaning approaches: first, we will outline the physiological changes in blood gases which should be expected from manipulations of ECBF, SGF and FdO2. Subsequently, we will describe the resulting adaptation of patients' control of breathing, with special reference to the effects of weaning on respiratory effort. Finally, we will discuss pertinent elements of the monitoring and mechanical ventilation of passive and spontaneously breathing patients during a weaning trial. Indeed, to avoid lung injury, invasive monitoring is often required in patients making spontaneous effort, as pressures measured at the airway may not reflect the degree of lung strain. In the absence of evidence, our approach to weaning is driven largely by an understanding of physiology.
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Affiliation(s)
- Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St. Thomas' National Health Service Foundation Trust, London, UK.
| | - Lorenzo Giosa
- grid.420545.20000 0004 0489 3985Department of Critical Care Medicine, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, UK ,grid.13097.3c0000 0001 2322 6764Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King’s College London, London, UK
| | - Valentina Camarda
- grid.420545.20000 0004 0489 3985Department of Critical Care Medicine, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, UK
| | - Luigi Camporota
- grid.420545.20000 0004 0489 3985Department of Critical Care Medicine, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, UK ,grid.13097.3c0000 0001 2322 6764Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King’s College London, London, UK
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20
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Right Ventricular Injury Increases Mortality in Patients With Acute Respiratory Distress Syndrome on Veno-Venous Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis. ASAIO J 2023; 69:e14-e22. [PMID: 36375040 DOI: 10.1097/mat.0000000000001854] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Right ventricular injury (RVI) in the context of acute respiratory distress syndrome (ARDS) is well recognized as an important determinant risk factor of mortality. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is part of the algorithm for the management of patients with severe ARDS and severely impaired gas exchange. Although VV-ECMO may theoretically protect the RV it is uncertain to what degree RVI persists despite VV-ECMO support, and whether it continues to influence mortality after ECMO initiation. The aim of this systematic review and meta-analysis was to investigate the impact of RVI on mortality in this context, testing the hypothesis that RVI worsens mortality in this cohort. We performed a systematic search that identified seven studies commenting on RVI and mortality in patients with ARDS receiving VV-ECMO. The presence of RVI was associated with greater mortality overall (odds ratios [OR]: 2.72; 95% confidence intervals [CI]: 1.52-4.85; p < 0.00) and across three subgroups (RV dilatational measures: OR: 3.51; 95% CI: 1.51-8.14; p < 0.01, RV functional measures: OR: 1.84; 95% CI: 0.99-3.42; p = 0.05, RV measurements post-ECMO initiation: OR: 1.94; 95% CI: 1.01-3.72; p < 0.05). Prospective studies are needed to investigate the causal relationship between RVI and mortality in this patient group and the best management strategies to reduce mortality.
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21
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Guervilly C, Fournier T, Chommeloux J, Arnaud L, Pinglis C, Baumstarck K, Boucekine M, Valera S, Sanz C, Adda M, Bobot M, Daviet F, Gragueb-Chatti I, Forel JM, Roch A, Hraiech S, Dignat-George F, Schmidt M, Lacroix R, Papazian L. Ultra-lung-protective ventilation and biotrauma in severe ARDS patients on veno-venous extracorporeal membrane oxygenation: a randomized controlled study. Crit Care 2022; 26:383. [PMID: 36510324 PMCID: PMC9744058 DOI: 10.1186/s13054-022-04272-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Ultra-lung-protective ventilation may be useful during veno-venous extracorporeal membrane oxygenation (vv-ECMO) for severe acute respiratory distress syndrome (ARDS) to minimize ventilator-induced lung injury and to facilitate lung recovery. The objective was to compare pulmonary and systemic biotrauma evaluated by numerous biomarkers of inflammation, epithelial, endothelial injuries, and lung repair according to two ventilator strategies on vv-ECMO. METHODS This is a prospective randomized controlled study. Patients were randomized to receive during 48 h either ultra-lung-protective ventilation combining very low tidal volume (1-2 mL/kg of predicted body weight), low respiratory rate (5-10 cycles per minute), positive expiratory transpulmonary pressure, and 16 h of prone position or lung-protective-ventilation which followed the ECMO arm of the EOLIA trial (control group). RESULTS The primary outcome was the alveolar concentrations of interleukin-1-beta, interleukin-6, interleukin-8, surfactant protein D, and blood concentrations of serum advanced glycation end products and angiopoietin-2 48 h after randomization. Enrollment was stopped for futility after the inclusion of 39 patients. Tidal volume, respiratory rate, minute ventilation, plateau pressure, and mechanical power were significantly lower in the ultra-lung-protective group. None of the concentrations of the pre-specified biomarkers differed between the two groups 48 h after randomization. However, a trend to higher 60-day mortality was observed in the ultra-lung-protective group compared to the control group (45 vs 17%, p = 0.06). CONCLUSIONS Despite a significant reduction in the mechanical power, ultra-lung-protective ventilation during 48 h did not reduce biotrauma in patients with vv-ECMO-supported ARDS. The impact of this ventilation strategy on clinical outcomes warrants further investigation. Trial registration Clinical trial registered with www. CLINICALTRIALS gov ( NCT03918603 ). Registered 17 April 2019.
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Affiliation(s)
- Christophe Guervilly
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Théotime Fournier
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France
| | - Juliette Chommeloux
- grid.411439.a0000 0001 2150 9058Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne, Université Hôpital Pitié- Salpêtrière, Paris, France ,grid.462844.80000 0001 2308 1657INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Laurent Arnaud
- grid.414336.70000 0001 0407 1584Laboratoire d’Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Camille Pinglis
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Karine Baumstarck
- grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Mohamed Boucekine
- grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Sabine Valera
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Celine Sanz
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Mélanie Adda
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Mickaël Bobot
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817INSERM 1263, Institut National de Recherche Pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre de Recherche en CardioVasculaire et Nutrition (C2VN), Université Aix-Marseille, Marseille, France ,grid.411535.70000 0004 0638 9491Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, CHU de la Conception, 13005 Marseille, France
| | - Florence Daviet
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Ines Gragueb-Chatti
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Jean-Marie Forel
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Antoine Roch
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Sami Hraiech
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Françoise Dignat-George
- grid.414336.70000 0001 0407 1584Laboratoire d’Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France ,grid.5399.60000 0001 2176 4817INSERM 1263, Institut National de Recherche Pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre de Recherche en CardioVasculaire et Nutrition (C2VN), Université Aix-Marseille, Marseille, France
| | - Matthieu Schmidt
- grid.411439.a0000 0001 2150 9058Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne, Université Hôpital Pitié- Salpêtrière, Paris, France ,grid.462844.80000 0001 2308 1657INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Romaric Lacroix
- grid.414336.70000 0001 0407 1584Laboratoire d’Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France ,grid.5399.60000 0001 2176 4817INSERM 1263, Institut National de Recherche Pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre de Recherche en CardioVasculaire et Nutrition (C2VN), Université Aix-Marseille, Marseille, France
| | - Laurent Papazian
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France ,Centre Hospitalier de Bastia, Service de Réanimation, 604 Chemin de Falconaja, 20600 Bastia, France
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Complications Associated With Venovenous Extracorporeal Membrane Oxygenation-What Can Go Wrong? Crit Care Med 2022; 50:1809-1818. [PMID: 36094523 DOI: 10.1097/ccm.0000000000005673] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Despite increasing use and promising outcomes, venovenous extracorporeal membrane oxygenation (V-V ECMO) introduces the risk of a number of complications across the spectrum of ECMO care. This narrative review describes the variety of short- and long-term complications that can occur during treatment with ECMO and how patient selection and management decisions may influence the risk of these complications. DATA SOURCES English language articles were identified in PubMed using phrases related to V-V ECMO, acute respiratory distress syndrome, severe respiratory failure, and complications. STUDY SELECTION Original research, review articles, commentaries, and published guidelines from the Extracorporeal Life support Organization were considered. DATA EXTRACTION Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS Selecting patients for V-V ECMO exposes the patient to a number of complications. Adequate knowledge of these risks is needed to weigh them against the anticipated benefit of treatment. Timing of ECMO initiation and transfer to centers capable of providing ECMO affect patient outcomes. Choosing a configuration that insufficiently addresses the patient's physiologic deficit leads to consequences of inadequate physiologic support. Suboptimal mechanical ventilator management during ECMO may lead to worsening lung injury, delayed lung recovery, or ventilator-associated pneumonia. Premature decannulation from ECMO as lungs recover can lead to clinical worsening, and delayed decannulation can prolong exposure to complications unnecessarily. Short-term complications include bleeding, thrombosis, and hemolysis, renal and neurologic injury, concomitant infections, and technical and mechanical problems. Long-term complications reflect the physical, functional, and neurologic sequelae of critical illness. ECMO can introduce ethical and emotional challenges, particularly when bridging strategies fail. CONCLUSIONS V-V ECMO is associated with a number of complications. ECMO selection, timing of initiation, and management decisions impact the presence and severity of these potential harms.
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Liao TY, Ruan SY, Lai CH, Tseng LJ, Keng LT, Chen YY, Wang CH, Chien JY, Wu HD, Chen YS, Yu CJ. Impact of ventilator settings during venovenous extracorporeal membrane oxygenation on clinical outcomes in influenza-associated acute respiratory distress syndrome: a multicenter retrospective cohort study. PeerJ 2022; 10:e14140. [PMID: 36248704 PMCID: PMC9558618 DOI: 10.7717/peerj.14140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 09/06/2022] [Indexed: 01/21/2023] Open
Abstract
Background Patients with influenza-associated acute respiratory distress syndrome (ARDS) requiring venovenous extracorporeal membrane oxygenation (vv-ECMO) support have a high mortality rate. Ventilator settings have been known to have a substantial impact on outcomes. However, the optimal settings of mechanical ventilation during vv-ECMO are still unknown. Methods This multicenter retrospective cohort study was conducted in the intensive care units (ICUs) of three tertiary referral hospitals in Taiwan between July 2009 and December 2019. It aims to describe the effect of ventilator settings during vv-ECMO on patient outcomes. Results A total of 93 patients with influenza receiving ECMO were screened. Patients were excluded if they: were receiving venoarterial ECMO, died within three days of vv-ECMO initiation, or were transferred to the tertiary referral hospital >24 hours after vv-ECMO initiation. A total of 62 patients were included in the study, and 24 (39%) died within six months. During the first three days of ECMO, there were no differences in tidal volume (5.1 vs. 5.2 mL/kg, p = 0.833), dynamic driving pressure (15 vs. 14 cmH2O, p = 0.146), and mechanical power (11.3 vs. 11.8 J/min, p = 0.352) between survivors and non-survivors. However, respiratory rates were significantly higher in non-survivors compared with survivors (15 vs. 12 breaths/min, p = 0.013). After adjustment for important confounders, a higher mean respiratory rate of >12 breaths/min was still associated with higher mortality (adjusted hazard ratio = 3.31, 95% confidence interval = 1.10-9.97, p = 0.034). Conclusions In patients with influenza-associated ARDS receiving vv-ECMO support, we found that a higher respiratory rate was associated with higher mortality. Respiratory rate might be a modifiable factor to improve outcomes in this patient population.
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Affiliation(s)
- Ting-Yu Liao
- Departments of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Sheng-Yuan Ruan
- Departments of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Heng Lai
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Jung Tseng
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Ta Keng
- Departments of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - You-Yi Chen
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu, Taiwan,Thoracic Medicine Center, Department of Medicine and Surgery, National Taiwan University Hospital Yunlin Branch, Dou-Liu, Taiwan
| | - Chih-Hsien Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jung-Yien Chien
- Departments of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Dong Wu
- Departments of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Departments of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan,Departments of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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24
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Zochios V, Brodie D, Shekar K, Schultz MJ, Parhar KKS. Invasive mechanical ventilation in patients with acute respiratory distress syndrome receiving extracorporeal support: a narrative review of strategies to mitigate lung injury. Anaesthesia 2022; 77:1137-1151. [PMID: 35864561 DOI: 10.1111/anae.15806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
Veno-venous extracorporeal membrane oxygenation is indicated in patients with acute respiratory distress syndrome and severely impaired gas exchange despite evidence-based lung protective ventilation, prone positioning and other parts of the standard algorithm for treating such patients. Extracorporeal support can facilitate ultra-lung-protective ventilation, meaning even lower volumes and pressures than standard lung-protective ventilation, by directly removing carbon dioxide in patients needing injurious ventilator settings to maintain sufficient gas exchange. Injurious ventilation results in ventilator-induced lung injury, which is one of the main determinants of mortality in acute respiratory distress syndrome. Marked reductions in the intensity of ventilation to the lowest tolerable levels under extracorporeal support may be achieved and could thereby potentially mitigate ventilator-induced lung injury and theoretically patient self-inflicted lung injury in spontaneously breathing patients with high respiratory drive. However, the benefits of this strategy may be counterbalanced by the use of continuous deep sedation and even neuromuscular blocking drugs, which may impair physical rehabilitation and impact long-term outcomes. There are currently a lack of large-scale prospective data to inform optimal invasive ventilation practices and how to best apply a holistic approach to patients receiving veno-venous extracorporeal membrane oxygenation, while minimising ventilator-induced and patient self-inflicted lung injury. We aimed to review the literature relating to invasive ventilation strategies in patients with acute respiratory distress syndrome receiving extracorporeal support and discuss personalised ventilation approaches and the potential role of adjunctive therapies in facilitating lung protection.
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Affiliation(s)
- V Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, UK.,Department of Cardiovascular Sciences, University of Leicester, UK
| | - D Brodie
- Columbia University College of Physicians and Surgeons, New York, NY, USA.,Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - K Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane and Bond University, Goldcoast, QLD, Australia
| | - M J Schultz
- Department of Intensive Care, Amsterdam University Medical Centres, Amsterdam, the Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland
| | - K K S Parhar
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
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Castro DM, Morris I, Teijeiro-Paradis R, Fan E. Monitoring during extracorporeal membrane oxygenation. Curr Opin Crit Care 2022; 28:348-359. [PMID: 35275878 DOI: 10.1097/mcc.0000000000000939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal membrane oxygenation (ECMO) offers advanced mechanical support to patients with severe acute respiratory and/or cardiac failure. Ensuring an adequate therapeutic approach as well as prevention of ECMO-associated complications, by means of timely liberation, forms an essential part of standard ECMO care and is only achievable through continuous monitoring and evaluation. This review focus on the cardiorespiratory monitoring tools that can be used to assess and titrate adequacy of ECMO therapy; as well as methods to assess readiness to wean and/or discontinue ECMO support. RECENT FINDINGS Surrogates of tissue perfusion and near infrared spectroscopy are not standards of care but may provide useful information in select patients. Echocardiography allows to determine cannulas position, evaluate cardiac structures, and function, and diagnose complications. Respiratory monitoring is mandatory to achieve lung protective ventilation and identify early lung recovery, surrogate measurements of respiratory effort and ECMO derived parameters are invaluable in optimally managing ECMO patients. SUMMARY Novel applications of existing monitoring modalities alongside evolving technological advances enable the advanced monitoring required for safe delivery of ECMO. Liberation trials are necessary to minimize time sensitive ECMO related complications; however, these have yet to be standardized.
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Affiliation(s)
- Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Idunn Morris
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Discipline of Intensive Care Medicine, Nepean Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | | | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital
- Institute of Health Policy, Management and Evaluation
- Department of Medicine, University of Toronto, Toronto, Canada
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Association of Respiratory Parameters at Venovenous Extracorporeal Membrane Oxygenation Liberation With Duration of Mechanical Ventilation and ICU Length of Stay: A Prospective Cohort Study. Crit Care Explor 2022; 4:e0689. [PMID: 35517643 PMCID: PMC9067359 DOI: 10.1097/cce.0000000000000689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Graf PT, Boesing C, Brumm I, Biehler J, Müller KW, Thiel M, Pelosi P, Rocco PRM, Luecke T, Krebs J. Ultraprotective versus apneic ventilation in acute respiratory distress syndrome patients with extracorporeal membrane oxygenation: a physiological study. J Intensive Care 2022; 10:12. [PMID: 35256012 PMCID: PMC8900404 DOI: 10.1186/s40560-022-00604-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/27/2022] [Indexed: 11/15/2022] Open
Abstract
Background Even an ultraprotective ventilation strategy in severe acute respiratory distress syndrome (ARDS) patients treated with extracorporeal membrane oxygenation (ECMO) might induce ventilator-induced lung injury and apneic ventilation with the sole application of positive end-expiratory pressure may, therefore, be an alternative ventilation strategy. We, therefore, compared the effects of ultraprotective ventilation with apneic ventilation on oxygenation, oxygen delivery, respiratory system mechanics, hemodynamics, strain, air distribution and recruitment of the lung parenchyma in ARDS patients with ECMO. Methods In a prospective, monocentric physiological study, 24 patients with severe ARDS managed with ECMO were ventilated using ultraprotective ventilation (tidal volume 3 ml/kg of predicted body weight) with a fraction of inspired oxygen (FiO2) of 21%, 50% and 90%. Patients were then treated with apneic ventilation with analogous FiO2. The primary endpoint was the effect of the ventilation strategy on oxygenation and oxygen delivery. The secondary endpoints were mechanical power, stress, regional air distribution, lung recruitment and the resulting strain, evaluated by chest computed tomography, associated with the application of PEEP (apneic ventilation) and/or low VT (ultraprotective ventilation). Results Protective ventilation, compared to apneic ventilation, improved oxygenation (arterial partial pressure of oxygen, p < 0.001 with FiO2 of 50% and 90%) and reduced cardiac output. Both ventilation strategies preserved oxygen delivery independent of the FiO2. Protective ventilation increased driving pressure, stress, strain, mechanical power, as well as induced additional recruitment in the non-dependent lung compared to apneic ventilation. Conclusions In patients with severe ARDS managed with ECMO, ultraprotective ventilation compared to apneic ventilation improved oxygenation, but increased stress, strain, and mechanical power. Apneic ventilation might be considered as one of the options in the initial phase of ECMO treatment in severe ARDS patients to facilitate lung rest and prevent ventilator-induced lung injury. Trial registration: German Clinical Trials Register (DRKS00013967). Registered 02/09/2018. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013967. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-022-00604-9.
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Garfield B, Handslip R, Patel BV. Ventilator-Associated Lung Injury. ENCYCLOPEDIA OF RESPIRATORY MEDICINE 2022. [PMCID: PMC8128668 DOI: 10.1016/b978-0-08-102723-3.00237-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ventilatory support, while life saving, can also cause or aggravate lung injury through several mechanisms which are encompassed within ventilator-associated lung injury (VALI). The important realizationin the acute respiratory distress syndrome that the “baby” lung resided in non-dependent areas led to the conceptualization of “lung rest” to reduce stress and strain to exposed alveolar units. We discuss concepts and mechanisms within VALI that ultimately induce maladaptive lung responses, as well as, current and future management strategies to detect and mitigate VALI at the bedside.
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Chiu LC, Kao KC. Mechanical Ventilation during Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome: A Narrative Review. J Clin Med 2021; 10:jcm10214953. [PMID: 34768478 PMCID: PMC8584351 DOI: 10.3390/jcm10214953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/15/2021] [Accepted: 10/25/2021] [Indexed: 12/12/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening condition involving acute hypoxemic respiratory failure. Mechanical ventilation remains the cornerstone of management for ARDS; however, potentially injurious mechanical forces introduce the risk of ventilator-induced lung injury, multiple organ failure, and death. Extracorporeal membrane oxygenation (ECMO) is a salvage therapy aimed at ensuring adequate gas exchange for patients suffering from severe ARDS with profound hypoxemia where conventional mechanical ventilation has failed. ECMO allows for lower tidal volumes and airway pressures, which can reduce the risk of further lung injury, and allow the lungs to rest. However, the collateral effect of ECMO should be considered. Recent studies have reported correlations between mechanical ventilator settings during ECMO and mortality. In many cases, mechanical ventilation settings should be tailored to the individual; however, researchers have yet to establish optimal ventilator settings or determine the degree to which ventilation load can be decreased. This paper presents an overview of previous studies and clinical trials pertaining to the management of mechanical ventilation during ECMO for patients with severe ARDS, with a focus on clinical findings, suggestions, protocols, guidelines, and expert opinions. We also identified a number of issues that have yet to be adequately addressed.
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Affiliation(s)
- Li-Chung Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan;
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan;
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan 33302, Taiwan
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
- Correspondence: ; Tel.: +886-3-3281200 (ext. 8467)
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Araos J, Alegria L, Garcia A, Cruces P, Soto D, Erranz B, Salomon T, Medina T, Garcia P, Dubó S, Bachmann MC, Basoalto R, Valenzuela ED, Rovegno M, Vera M, Retamal J, Cornejo R, Bugedo G, Bruhn A. 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. Br J Anaesth 2021; 127:807-814. [PMID: 34507822 PMCID: PMC8449633 DOI: 10.1016/j.bja.2021.07.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/09/2021] [Accepted: 07/26/2021] [Indexed: 01/19/2023] Open
Abstract
Background Lung rest has been recommended during extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS). Whether positive end-expiratory pressure (PEEP) confers lung protection during ECMO for severe ARDS is unclear. We compared the effects of three different PEEP levels whilst applying near-apnoeic ventilation in a model of severe ARDS treated with ECMO. Methods Acute respiratory distress syndrome was induced in anaesthetised adult male pigs by repeated saline lavage and injurious ventilation for 1.5 h. After ECMO was commenced, the pigs received standardised near-apnoeic ventilation for 24 h to maintain similar driving pressures and were randomly assigned to PEEP of 0, 10, or 20 cm H2O (n=7 per group). Respiratory and haemodynamic data were collected throughout the study. Histological injury was assessed by a pathologist masked to PEEP allocation. Lung oedema was estimated by wet-to-dry-weight ratio. Results All pigs developed severe ARDS. Oxygenation on ECMO improved with PEEP of 10 or 20 cm H2O, but did not in pigs allocated to PEEP of 0 cm H2O. Haemodynamic collapse refractory to norepinephrine (n=4) and early death (n=3) occurred after PEEP 20 cm H2O. The severity of lung injury was lowest after PEEP of 10 cm H2O in both dependent and non-dependent lung regions, compared with PEEP of 0 or 20 cm H2O. A higher wet-to-dry-weight ratio, indicating worse lung injury, was observed with PEEP of 0 cm H2O. Histological assessment suggested that lung injury was minimised with PEEP of 10 cm H2O. Conclusions During near-apnoeic ventilation and ECMO in experimental severe ARDS, 10 cm H2O PEEP minimised lung injury and improved gas exchange without compromising haemodynamic stability.
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Affiliation(s)
- Joaquin Araos
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Leyla Alegria
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Aline Garcia
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Cruces
- Center of Acute Respiratory Critical Illness, Santiago, Chile; Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile; Unidad de Pacientes Críticos Pediátrica, Hospital El Carmen Dr Luis Valentín Ferrada, Santiago, Chile
| | - Dagoberto Soto
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Benjamín Erranz
- Centro de Medicina Regenerativa, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Tatiana Salomon
- Unidad de Pacientes Críticos Pediátrica, Clínica Alemana, Santiago, Chile
| | - Tania Medina
- Unidad de Pacientes Críticos Pediátrica, Hospital El Carmen Dr Luis Valentín Ferrada, Santiago, Chile
| | - Patricio Garcia
- Departamento de Ciencias de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sebastián Dubó
- Departamento de Kinesiología, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
| | - María C Bachmann
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Roque Basoalto
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Emilio D Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Magdalena Vera
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Center of Acute Respiratory Critical Illness, Santiago, Chile
| | - Rodrigo Cornejo
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile; Center of Acute Respiratory Critical Illness, Santiago, Chile
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Center of Acute Respiratory Critical Illness, Santiago, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Center of Acute Respiratory Critical Illness, Santiago, Chile.
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Individualized Multimodal Physiologic Approach to Mechanical Ventilation in Patients With Obesity and Severe Acute Respiratory Distress Syndrome Reduced Venovenous Extracorporeal Membrane Oxygenation Utilization. Crit Care Explor 2021; 3:e0461. [PMID: 34235455 PMCID: PMC8245114 DOI: 10.1097/cce.0000000000000461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVE: To investigate whether individualized optimization of mechanical ventilation through the implementation of a lung rescue team could reduce the need for venovenous extracorporeal membrane oxygenation in patients with obesity and acute respiratory distress syndrome and decrease ICU and hospital length of stay and mortality. DESIGN: Single-center, retrospective study at the Massachusetts General Hospital from June 2015 to June 2019. PATIENTS: All patients with obesity and acute respiratory distress syndrome who were referred for venovenous extracorporeal membrane oxygenation evaluation due to hypoxemic respiratory failure. INTERVENTION: Evaluation and individualized optimization of mechanical ventilation by the lung rescue team before the decision to proceed with venovenous extracorporeal membrane oxygenation. The control group was those patients managed according to hospital standard of care without lung rescue team evaluation. MEASUREMENT AND MAIN RESULTS: All 20 patients (100%) allocated in the control group received venovenous extracorporeal membrane oxygenation, whereas 10 of 13 patients (77%) evaluated by the lung rescue team did not receive venovenous extracorporeal membrane oxygenation. Patients who underwent lung rescue team evaluation had a shorter duration of mechanical ventilation (p = 0.03) and shorter ICU length of stay (p = 0.03). There were no differences between groups in in-hospital, 30-day, or 1–year mortality. CONCLUSIONS: In this hypothesis-generating study, individualized optimization of mechanical ventilation of patients with acute respiratory distress syndrome and obesity by a lung rescue team was associated with a decrease in the utilization of venovenous extracorporeal membrane oxygenation, duration of mechanical ventilation, and ICU length of stay. Mortality was not modified by the lung rescue team intervention.
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Will Not Breathing on Extracorporeal Membrane Oxygenation Help One Survive Acute Respiratory Distress Syndrome? Crit Care Med 2021; 48:1901-1904. [PMID: 33255109 DOI: 10.1097/ccm.0000000000004647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
PURPOSE OF REVIEW Assess the most recent studies using driving pressure (DP) as a monitoring technique under mechanical ventilation and describe the technical challenges associated with its measurement. RECENT FINDINGS DP is consistently associated with survival in acute respiratory failure and acute respiratory distress syndrome (ARDS) and can detect patients at higher risk of ventilator-induced lung injury. Its measurement can be challenged by leaks and ventilator dyssynchrony, but is also feasible under pressure support ventilation. Interestingly, an aggregated summary of published results suggests that its level is on average slightly lower in patients with coronavirus disease-19 induced ARDS than in classical ARDS. SUMMARY The DP is easy to obtain and should be incorporated as a minimal monitoring technique under mechanical ventilation.
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Extracorporeal Gas Exchange for Acute Respiratory Distress Syndrome: Open Questions, Controversies and Future Directions. MEMBRANES 2021; 11:membranes11030172. [PMID: 33670987 PMCID: PMC7997339 DOI: 10.3390/membranes11030172] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 02/06/2023]
Abstract
Veno-venous extracorporeal membrane oxygenation (V-V ECMO) in acute respiratory distress syndrome (ARDS) improves gas exchange and allows lung rest, thus minimizing ventilation-induced lung injury. In the last forty years, a major technological and clinical improvement allowed to dramatically improve the outcome of patients treated with V-V ECMO. However, many aspects of the care of patients on V-V ECMO remain debated. In this review, we will focus on main issues and controversies on caring of ARDS patients on V-V ECMO support. Particularly, the indications to V-V ECMO and the feasibility of a less invasive extracorporeal carbon dioxide removal will be discussed. Moreover, the controversies on management of mechanical ventilation, prone position and sedation will be explored. In conclusion, we will discuss evidences on transfusions and management of anticoagulation, also focusing on patients who undergo simultaneous treatment with ECMO and renal replacement therapy. This review aims to discuss all these clinical aspects with an eye on future directions and perspectives.
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Spadaro S, Fogagnolo A, Campo G, Zucchetti O, Verri M, Ottaviani I, Tunstall T, Grasso S, Scaramuzzo V, Murgolo F, Marangoni E, Vieceli Dalla Sega F, Fortini F, Pavasini R, Rizzo P, Ferrari R, Papi A, Volta CA, Contoli M. Markers of endothelial and epithelial pulmonary injury in mechanically ventilated COVID-19 ICU patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:74. [PMID: 33608030 PMCID: PMC7894238 DOI: 10.1186/s13054-021-03499-4] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/10/2021] [Indexed: 01/15/2023]
Abstract
Background Biomarkers can be used to detect the presence of endothelial and/or alveolar epithelial injuries in case of ARDS. Angiopoietin-2 (Ang-2), soluble intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion protein-1 (VCAM-1), P-selectin and E-selectin are biomarkers of endothelial injury, whereas the receptor for advanced glycation end-products (RAGE) reflects alveolar epithelial injury. The aims of this study were to evaluate whether the plasma concentration of the above-mentioned biomarkers was different 1) in survivors and non-survivors of COVID-19-related ARDS and 2) in COVID-19-related and classical ARDS. Methods This prospective study was performed in two COVID-19-dedicated Intensive Care Units (ICU) and one non-COVID-19 ICU at Ferrara University Hospital. A cohort of 31 mechanically ventilated patients with COVID-19 ARDS and a cohort of 11 patients with classical ARDS were enrolled. Ang-2, ICAM-1, VCAM-1, P-selectin, E-selectin and RAGE were determined with a bead-based multiplex immunoassay at three time points: inclusion in the study (T1), after 7 ± 2 days (T2) and 14 ± 2 days (T3). The primary outcome was to evaluate the plasma trend of the biomarker levels in survivors and non-survivors. The secondary outcome was to evaluate the differences in respiratory mechanics variables and gas exchanges between survivors and non-survivors. Furthermore, we compared the plasma levels of the biomarkers at T1 in patients with COVID-19-related ARDS and classical ARDS. Results In COVID-19-related ARDS, the plasma levels of Ang-2 and ICAM-1 at T1 were statistically higher in non-survivors than survivors, (p = 0.04 and p = 0.03, respectively), whereas those of P-selectin, E-selectin and RAGE did not differ. Ang-2 and ICAM-1 at T1 were predictors of mortality (AUROC 0.650 and 0.717, respectively). At T1, RAGE and P-selectin levels were higher in classical ARDS than in COVID-19-related ARDS. Ang-2, ICAM-1 and E-selectin were lower in classical ARDS than in COVID-19-related ARDS (all p < 0.001). Conclusions COVID-19 ARDS is characterized by an early pulmonary endothelial injury, as detected by Ang-2 and ICAM-1. COVID-19 ARDS and classical ARDS exhibited a different expression of biomarkers, suggesting different pathological pathways. Trial registration NCT04343053, Date of registration: April 13, 2020
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Affiliation(s)
- Savino Spadaro
- Intensive Care Unit, Department of Translational medicine and for Romagna, University of Ferrara, Azienda Ospedaliera Universitaria di Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.
| | - Alberto Fogagnolo
- Intensive Care Unit, Department of Translational medicine and for Romagna, University of Ferrara, Azienda Ospedaliera Universitaria di Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, FE, Italy.,Maria Cecilia Hospital, GVM Care and Research, Cotignola, RA, Italy
| | - Ottavio Zucchetti
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, FE, Italy.,Maria Cecilia Hospital, GVM Care and Research, Cotignola, RA, Italy
| | - Marco Verri
- Intensive Care Unit, Department of Translational medicine and for Romagna, University of Ferrara, Azienda Ospedaliera Universitaria di Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Irene Ottaviani
- Intensive Care Unit, Department of Translational medicine and for Romagna, University of Ferrara, Azienda Ospedaliera Universitaria di Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Tanushree Tunstall
- Department of Infection Biology, School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Salvatore Grasso
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Valentina Scaramuzzo
- Intensive Care Unit, Department of Translational medicine and for Romagna, University of Ferrara, Azienda Ospedaliera Universitaria di Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Francesco Murgolo
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Elisabetta Marangoni
- Intensive Care Unit, Department of Translational medicine and for Romagna, University of Ferrara, Azienda Ospedaliera Universitaria di Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Francesco Vieceli Dalla Sega
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesca Fortini
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Rita Pavasini
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, FE, Italy
| | - Paola Rizzo
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, RA, Italy.,Department of Morphology, Surgery, and Experimental Medicine, Laboratory for Technologies of Advanced Therapies, University of Ferrara, Ferrara, Italy
| | - Roberto Ferrari
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, FE, Italy.,Maria Cecilia Hospital, GVM Care and Research, Cotignola, RA, Italy
| | - Alberto Papi
- Respiratory Section, Department of Morphology, Surgery, and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Carlo Alberto Volta
- Intensive Care Unit, Department of Translational medicine and for Romagna, University of Ferrara, Azienda Ospedaliera Universitaria di Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Marco Contoli
- Respiratory Section, Department of Morphology, Surgery, and Experimental Medicine, University of Ferrara, Ferrara, Italy
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Belliato M, Epis F, Cremascoli L, Ferrari F, Quattrone MG, Fisser C, Malfertheiner MV, Taccone FS, Di Nardo M, Broman LM, Lorusso R. Mechanical Power during Veno-Venous Extracorporeal Membrane Oxygenation Initiation: A Pilot-Study. MEMBRANES 2021; 11:membranes11010030. [PMID: 33401668 PMCID: PMC7824596 DOI: 10.3390/membranes11010030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/27/2020] [Accepted: 12/29/2020] [Indexed: 12/27/2022]
Abstract
Mechanical power (MP) represents a useful parameter to describe and quantify the forces applied to the lungs during mechanical ventilation (MV). In this multi-center, prospective, observational study, we analyzed MP variations following MV adjustments after veno-venous extra-corporeal membrane oxygenation (VV ECMO) initiation. We also investigated whether the MV parameters (including MP) in the early phases of VV ECMO run may be related to the intensive care unit (ICU) mortality. Thirty-five patients with severe acute respiratory distress syndrome were prospectively enrolled and analyzed. After VV ECMO initiation, we observed a significant decrease in median MP (32.4 vs. 8.2 J/min, p < 0.001), plateau pressure (27 vs. 21 cmH2O, p = 0.012), driving pressure (11 vs. 8 cmH2O, p = 0.014), respiratory rate (RR, 22 vs. 14 breaths/min, p < 0.001), and tidal volume adjusted to patient ideal body weight (VT/IBW, 5.5 vs. 4.0 mL/kg, p = 0.001) values. During the early phase of ECMO run, RR (17 vs. 13 breaths/min, p = 0.003) was significantly higher, while positive end-expiratory pressure (10 vs. 14 cmH2O, p = 0.048) and VT/IBW (3.0 vs. 4.0 mL/kg, p = 0.028) were lower in ICU non-survivors, when compared to the survivors. The observed decrease in MP after ECMO initiation did not influence ICU outcome. Waiting for large studies assessing the role of these parameters in VV ECMO patients, RR and MP monitoring should not be underrated during ECMO.
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Affiliation(s)
- Mirko Belliato
- 2nd Intensive Care Unit, UOC Anestesia e Rianimazione II Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Francesco Epis
- 2nd Intensive Care Unit, UOC Anestesia e Rianimazione II Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
- Correspondence: ; Tel.: +39-0382-503524
| | - Luca Cremascoli
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, 27100 Pavia, Italy; (L.C.); (M.G.Q.)
| | - Fiorenza Ferrari
- 1st Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, 36100 Vicenza, Italy
| | - Maria Giovanna Quattrone
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, 27100 Pavia, Italy; (L.C.); (M.G.Q.)
| | - Christoph Fisser
- Department of Internal Medicine II, Cardiology and Pneumology, Intensive Care, University Hospital Regensburg, 93053 Regensburg, Germany; (C.F.); (M.V.M.)
| | - Maximilian Valentin Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, Intensive Care, University Hospital Regensburg, 93053 Regensburg, Germany; (C.F.); (M.V.M.)
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Cliniques Universitaires de Brussels, 1070 Brussels, Belgium;
| | - Matteo Di Nardo
- Pediatric Intensive Care, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, and Department of Physiology and Pharmacology, Karolinska Institutet, 171 64 Solna (Stockholm), Sweden;
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), 6229 HX Maastricht, The Netherlands;
- Cardiovascular Research Institute Maastricht (CARIM), 6229 ER Maastricht, The Netherlands
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