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Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort.
Am J Respir Crit Care Med. 2019 10 15; 200(8):1002-1012.AJ

Abstract

Rationale:

Current practices regarding mechanical ventilation in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown.

Objectives:

To report current practices regarding mechanical ventilation in patients treated with ECMO for severe acute respiratory distress syndrome (ARDS) and their association with 6-month outcomes.

Methods:

This was an international, multicenter, prospective cohort study of patients undergoing ECMO for ARDS during a 1-year period in 23 international ICUs.

Measurements and Main Results:

We collected demographics, daily pre- and per-ECMO mechanical ventilation settings and use of adjunctive therapies, ICU, and 6-month outcome data for 350 patients (mean ± SD pre-ECMO PaO2/FiO2 71 ± 34 mm Hg). Pre-ECMO use of prone positioning and neuromuscular blockers were 26% and 62%, respectively. Vt (6.4 ± 2.0 vs. 3.7 ± 2.0 ml/kg), plateau pressure (32 ± 7 vs. 24 ± 7 cm H2O), driving pressure (20 ± 7 vs. 14 ± 4 cm H2O), respiratory rate (26 ± 8 vs. 14 ± 6 breaths/min), and mechanical power (26.1 ± 12.7 vs. 6.6 ± 4.8 J/min) were markedly reduced after ECMO initiation. Six-month survival was 61%. No association was found between ventilator settings during the first 2 days of ECMO and survival in multivariable analysis. A time-varying Cox model retained older age, higher fluid balance, higher lactate, and more need for renal-replacement therapy along the ECMO course as being independently associated with 6-month mortality. A higher Vt and lower driving pressure (likely markers of static compliance improvement) across the ECMO course were also associated with better outcomes.

Conclusions:

Ultraprotective lung ventilation on ECMO was largely adopted across medium- to high-case volume ECMO centers. In contrast with previous observations, mechanical ventilation settings during ECMO did not impact patients' prognosis in this context.

Authors+Show Affiliations

INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, UPMC Univ Paris 06, Sorbonne Université, Paris, France. Assistance Publique-Hôpitaux de Paris, Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Paris, France.Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada. Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.Department of Anesthesia and Intensive Care, IRCCS-ISMETT Istituto Mediterraneo per i Trapianti e terapie ad alta specializzazione, Palermo, Italy.Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York.Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan.Intensive Care Unit, Alfred Hospital, Melbourne, Australia.Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom.Center for Studies and Research on Health Services and Quality of Life EA3279, Service de Medecine Intensive et Reanimation, CHU Hopital Nord, Assistance Publique Hôpitaux de Marseille, Aix-Marseille University, Marseille, France.Cardiothoracic & Vascular ICU, Auckland City Hospital, Auckland, New Zealand.Pôle de Recherche Cardiovasculaire, Institute de Recherche Expérimentale et Clinique, Cardiothoracic Intensive Care, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.St. Vincent's Hospital, New South Wales, Sydney, Australia.Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney University Medical School, Sydney, New South Wales, Australia.Department of Adult Intensive Care, Queen Mary Hospital, the University of Hong Kong, Hong Kong.Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts.Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland.Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong.University of Maryland, Baltimore, Maryland.Academic Medical Center, Amsterdam, the Netherlands.Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, AP-HP, Paris, France. UMR1148, LVTS, Sorbonne Paris Cité, Inserm/Paris Diderot University, Paris, France.Cardiothoracic and Vascular Intensive Care Unit, Amiens University Hospital, Amiens, France. INSERM U1088, Jules Verne University of Picardy, Amiens, France.Assistance Publique des Hôpitaux de Paris, Groupe Hospitalier Universitaire de Paris Centre, Médecine Intensive RéanimationHôpital Cochin, Paris, France. Paris Descartes Sorbonne Paris Cité University, Paris, France. Department of Infection, Immunity and Inflammation, Cochin Institute, Inserm U1016, Paris, France.South Department of Anesthesiology and Critical Care, Bordeaux University Hospital, Pessac, France.Service de Réanimation Médicale, Centre Hospitalier Universitaire d'Angers, Angers, France.Department of Critical Care Medicine, St. Vincent's Hospital Melbourne, Fitzroy, Australia.Intensive Care Unit, Alfred Hospital, Melbourne, Australia. Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.Biostatistics Team, Saint-Louis Hospital, AP-HP, Paris, France; and. ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (CRESS), INSERM, Paris Diderot Sorbonne University, Paris, France.Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York.INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, UPMC Univ Paris 06, Sorbonne Université, Paris, France. Assistance Publique-Hôpitaux de Paris, Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Paris, France.

Pub Type(s)

Journal Article
Multicenter Study

Language

eng

PubMed ID

31144997

Citation

Schmidt, Matthieu, et al. "Mechanical Ventilation Management During Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. an International Multicenter Prospective Cohort." American Journal of Respiratory and Critical Care Medicine, vol. 200, no. 8, 2019, pp. 1002-1012.
Schmidt M, Pham T, Arcadipane A, et al. Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort. Am J Respir Crit Care Med. 2019;200(8):1002-1012.
Schmidt, M., Pham, T., Arcadipane, A., Agerstrand, C., Ohshimo, S., Pellegrino, V., Vuylsteke, A., Guervilly, C., McGuinness, S., Pierard, S., Breeding, J., Stewart, C., Ching, S. S. W., Camuso, J. M., Stephens, R. S., King, B., Herr, D., Schultz, M. J., Neuville, M., ... Combes, A. (2019). Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort. American Journal of Respiratory and Critical Care Medicine, 200(8), 1002-1012. https://doi.org/10.1164/rccm.201806-1094OC
Schmidt M, et al. Mechanical Ventilation Management During Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. an International Multicenter Prospective Cohort. Am J Respir Crit Care Med. 2019 10 15;200(8):1002-1012. PubMed PMID: 31144997.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort. AU - Schmidt,Matthieu, AU - Pham,Tài, AU - Arcadipane,Antonio, AU - Agerstrand,Cara, AU - Ohshimo,Shinichiro, AU - Pellegrino,Vincent, AU - Vuylsteke,Alain, AU - Guervilly,Christophe, AU - McGuinness,Shay, AU - Pierard,Sophie, AU - Breeding,Jeff, AU - Stewart,Claire, AU - Ching,Simon Sin Wai, AU - Camuso,Janice M, AU - Stephens,R Scott, AU - King,Bobby, AU - Herr,Daniel, AU - Schultz,Marcus J, AU - Neuville,Mathilde, AU - Zogheib,Elie, AU - Mira,Jean-Paul, AU - Rozé,Hadrien, AU - Pierrot,Marc, AU - Tobin,Anthony, AU - Hodgson,Carol, AU - Chevret,Sylvie, AU - Brodie,Daniel, AU - Combes,Alain, PY - 2019/5/31/pubmed PY - 2020/3/24/medline PY - 2019/5/31/entrez KW - ECMO KW - acute respiratory distress syndrome KW - mechanical ventilation KW - outcome KW - prone position SP - 1002 EP - 1012 JF - American journal of respiratory and critical care medicine JO - Am J Respir Crit Care Med VL - 200 IS - 8 N2 - Rationale: Current practices regarding mechanical ventilation in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown.Objectives: To report current practices regarding mechanical ventilation in patients treated with ECMO for severe acute respiratory distress syndrome (ARDS) and their association with 6-month outcomes.Methods: This was an international, multicenter, prospective cohort study of patients undergoing ECMO for ARDS during a 1-year period in 23 international ICUs.Measurements and Main Results: We collected demographics, daily pre- and per-ECMO mechanical ventilation settings and use of adjunctive therapies, ICU, and 6-month outcome data for 350 patients (mean ± SD pre-ECMO PaO2/FiO2 71 ± 34 mm Hg). Pre-ECMO use of prone positioning and neuromuscular blockers were 26% and 62%, respectively. Vt (6.4 ± 2.0 vs. 3.7 ± 2.0 ml/kg), plateau pressure (32 ± 7 vs. 24 ± 7 cm H2O), driving pressure (20 ± 7 vs. 14 ± 4 cm H2O), respiratory rate (26 ± 8 vs. 14 ± 6 breaths/min), and mechanical power (26.1 ± 12.7 vs. 6.6 ± 4.8 J/min) were markedly reduced after ECMO initiation. Six-month survival was 61%. No association was found between ventilator settings during the first 2 days of ECMO and survival in multivariable analysis. A time-varying Cox model retained older age, higher fluid balance, higher lactate, and more need for renal-replacement therapy along the ECMO course as being independently associated with 6-month mortality. A higher Vt and lower driving pressure (likely markers of static compliance improvement) across the ECMO course were also associated with better outcomes.Conclusions: Ultraprotective lung ventilation on ECMO was largely adopted across medium- to high-case volume ECMO centers. In contrast with previous observations, mechanical ventilation settings during ECMO did not impact patients' prognosis in this context. SN - 1535-4970 UR - https://www.unboundmedicine.com/medline/citation/31144997/Mechanical_Ventilation_Management_during_Extracorporeal_Membrane_Oxygenation_for_Acute_Respiratory_Distress_Syndrome__An_International_Multicenter_Prospective_Cohort_ L2 - https://www.atsjournals.org/doi/10.1164/rccm.201806-1094OC?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -