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Ultra-Protective Ventilation Reduces Biotrauma in Patients on Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome.
Crit Care Med. 2019 11; 47(11):1505-1512.CC

Abstract

INTRODUCTION

Ventilator settings for patients with severe acute respiratory distress syndrome supported by venovenous extracorporeal membrane oxygenation are currently set arbitrarily. The impact on serum and pulmonary biotrauma markers of the transition to ultra-protective ventilation settings following extracorporeal membrane oxygenation implantation, and different mechanical ventilation strategies while on extracorporeal membrane oxygenation were investigated.

DESIGN

Randomized clinical trial.

SETTINGS

Nine-month monocentric study.

PATIENTS

Severe acute respiratory distress syndrome patients on venovenous extracorporeal membrane oxygenation.

INTERVENTIONS

After starting extracorporeal membrane oxygenation, patients were switched to the bi-level positive airway pressure mode with 1 second of 24 cm H2O high pressure and 2 seconds of 12 cm H2O low pressure for 24 hours. A computer-generated allocation sequence randomized patients to receive each of the following three experimental steps: 1) high pressure 24 cm H2O and low pressure 20 cm H2O (very high positive end-expiratory pressure-very low driving pressure); 2) high pressure 24 cm H2O and low pressure 5 cm H2O (low positive end-expiratory pressure-high driving pressure); and 3) high pressure 17 cm H2O and low pressure 5 cm H2O (low positive end-expiratory pressure-low driving pressure). Plasma and bronchoalveolar lavage soluble receptor for advanced glycation end-products, plasma interleukin-6, and monocyte chemotactic protein-1 were sampled preextracorporeal membrane oxygenation and after 12 hours at each step.

MEASUREMENTS AND MAIN RESULTS

Sixteen patients on ECMO after 7 days (1-11 d) of mechanical ventilation were included. "Ultra-protective" mechanical ventilation settings following ECMO initiation were associated with significantly lower plasma sRAGE, interleukin-6, and monocyte chemotactic protein-1 concentrations. Plasma sRAGE and cytokines were comparable within each on-ECMO experimental step, but the lowest bronchoalveolar lavage sRAGE levels were obtained at minimal driving pressure.

CONCLUSIONS

ECMO allows ultra- protective ventilation, which combines significantly lower plateau pressure, tidalvolume, and driving pressure. This ventilation strategy significantly limited pulmonary biotrauma, which couldtherefore decrease ventilator-induced lung injury. However, the optimal ultra-protective ventilation strategy once ECMO is initiated remains undetermined and warrants further investigations. (Crit Care Med 2019; 47:1505-1512).

Authors+Show Affiliations

Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France.Département d'Immunologie, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, 75651 Paris Cedex 13, France. Sorbonne Université, UPMC Univ Paris 06, CIMI, INSERM U_1135, Paris, France.Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France.Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France.Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France.Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France.Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France. Department of Cardiovascular and Thoracic Surgery, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, 75651 Paris Cedex 13, France.Département d'Immunologie, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, 75651 Paris Cedex 13, France. Sorbonne Université, UPMC Univ Paris 06, CIMI, INSERM U_1135, Paris, France.Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France.Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France.Sorbonne Université, UPMC Univ Paris 06, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, 75651 Paris Cedex 13, France. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, 75651 Paris Cedex 13, France.

Pub Type(s)

Journal Article
Randomized Controlled Trial

Language

eng

PubMed ID

31385880

Citation

Rozencwajg, Sacha, et al. "Ultra-Protective Ventilation Reduces Biotrauma in Patients On Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome." Critical Care Medicine, vol. 47, no. 11, 2019, pp. 1505-1512.
Rozencwajg S, Guihot A, Franchineau G, et al. Ultra-Protective Ventilation Reduces Biotrauma in Patients on Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. Crit Care Med. 2019;47(11):1505-1512.
Rozencwajg, S., Guihot, A., Franchineau, G., Lescroat, M., Bréchot, N., Hékimian, G., Lebreton, G., Autran, B., Luyt, C. E., Combes, A., & Schmidt, M. (2019). Ultra-Protective Ventilation Reduces Biotrauma in Patients on Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. Critical Care Medicine, 47(11), 1505-1512. https://doi.org/10.1097/CCM.0000000000003894
Rozencwajg S, et al. Ultra-Protective Ventilation Reduces Biotrauma in Patients On Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. Crit Care Med. 2019;47(11):1505-1512. PubMed PMID: 31385880.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Ultra-Protective Ventilation Reduces Biotrauma in Patients on Venovenous Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. AU - Rozencwajg,Sacha, AU - Guihot,Amélie, AU - Franchineau,Guillaume, AU - Lescroat,Mickael, AU - Bréchot,Nicolas, AU - Hékimian,Guillaume, AU - Lebreton,Guillaume, AU - Autran,Brigitte, AU - Luyt,Charles-Edouard, AU - Combes,Alain, AU - Schmidt,Matthieu, PY - 2019/8/7/pubmed PY - 2020/5/26/medline PY - 2019/8/7/entrez SP - 1505 EP - 1512 JF - Critical care medicine JO - Crit Care Med VL - 47 IS - 11 N2 - INTRODUCTION: Ventilator settings for patients with severe acute respiratory distress syndrome supported by venovenous extracorporeal membrane oxygenation are currently set arbitrarily. The impact on serum and pulmonary biotrauma markers of the transition to ultra-protective ventilation settings following extracorporeal membrane oxygenation implantation, and different mechanical ventilation strategies while on extracorporeal membrane oxygenation were investigated. DESIGN: Randomized clinical trial. SETTINGS: Nine-month monocentric study. PATIENTS: Severe acute respiratory distress syndrome patients on venovenous extracorporeal membrane oxygenation. INTERVENTIONS: After starting extracorporeal membrane oxygenation, patients were switched to the bi-level positive airway pressure mode with 1 second of 24 cm H2O high pressure and 2 seconds of 12 cm H2O low pressure for 24 hours. A computer-generated allocation sequence randomized patients to receive each of the following three experimental steps: 1) high pressure 24 cm H2O and low pressure 20 cm H2O (very high positive end-expiratory pressure-very low driving pressure); 2) high pressure 24 cm H2O and low pressure 5 cm H2O (low positive end-expiratory pressure-high driving pressure); and 3) high pressure 17 cm H2O and low pressure 5 cm H2O (low positive end-expiratory pressure-low driving pressure). Plasma and bronchoalveolar lavage soluble receptor for advanced glycation end-products, plasma interleukin-6, and monocyte chemotactic protein-1 were sampled preextracorporeal membrane oxygenation and after 12 hours at each step. MEASUREMENTS AND MAIN RESULTS: Sixteen patients on ECMO after 7 days (1-11 d) of mechanical ventilation were included. "Ultra-protective" mechanical ventilation settings following ECMO initiation were associated with significantly lower plasma sRAGE, interleukin-6, and monocyte chemotactic protein-1 concentrations. Plasma sRAGE and cytokines were comparable within each on-ECMO experimental step, but the lowest bronchoalveolar lavage sRAGE levels were obtained at minimal driving pressure. CONCLUSIONS: ECMO allows ultra- protective ventilation, which combines significantly lower plateau pressure, tidalvolume, and driving pressure. This ventilation strategy significantly limited pulmonary biotrauma, which couldtherefore decrease ventilator-induced lung injury. However, the optimal ultra-protective ventilation strategy once ECMO is initiated remains undetermined and warrants further investigations. (Crit Care Med 2019; 47:1505-1512). SN - 1530-0293 UR - https://www.unboundmedicine.com/medline/citation/31385880/Ultra_Protective_Ventilation_Reduces_Biotrauma_in_Patients_on_Venovenous_Extracorporeal_Membrane_Oxygenation_for_Severe_Acute_Respiratory_Distress_Syndrome_ L2 - https://dx.doi.org/10.1097/CCM.0000000000003894 DB - PRIME DP - Unbound Medicine ER -