Mechanical Ventilation Management During Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. Issue 3 (March 2015)

• Record Type: Journal Article
• Authors: Schmidt, Matthieu; Stewart, Claire; Bailey, Michael; Nieszkowska, Ania; Kelly, Joshua; Murphy, Lorna; Pilcher, David; Cooper, D. James; Scheinkestel, Carlos; Pellegrino, Vincent; Forrest, Paul; Combes, Alain; Hodgson, Carol
• Is Part Of: Critical care medicine. Volume 43:Issue 3(2015)
• Publication Date: 2015-03
• Subjects: Critical care medicine -- Periodicals; Soins intensifs -- Périodiques; 616.028
• DOI: 10.1097/CCM.0000000000000753
• Languages: English
• ISSNs: 0090-3493

Abstract

<abstract> <title> <x xml:space="preserve">Abstract</x> </title> <sec> <title>Objective:</title> <p>To describe mechanical ventilation settings in adult patients treated for an acute respiratory distress syndrome with extracorporeal membrane oxygenation and assess the potential impact of mechanical ventilation settings on ICU mortality.</p> </sec> <sec> <title>Design:</title> <p>Retrospective observational study.</p> </sec> <sec> <title>Setting:</title> <p>Three international high-volume extracorporeal membrane oxygenation centers.</p> </sec> <sec> <title>Patients:</title> <p>A total of 168 patients treated with extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from January 2007 to January 2013.</p> </sec> <sec> <title>Interventions:</title> <p>We analyzed the association between mechanical ventilation settings (i.e. plateau pressure, tidal volume, and positive end-expiratory pressure) on ICU mortality using multivariable logistic regression model and Cox-proportional hazards model.</p> </sec> <sec> <title>Measurement and Main Results:</title> <p>We obtained detailed demographic, clinical, daily mechanical ventilation settings and ICU outcome data. One hundred sixty-eight patients (41 ± 14 years old; PaO<sub>2</sub>/FIO<sub>2</sub> 67 ± 19 mm Hg) fulfilled our inclusion criteria. Median duration of extracorporeal membrane oxygenation and ICU stay were 10 days (6–18 d) and 28 days (16–42 d), respectively. Lower positive end-expiratory pressure levels and significantly lower plateau pressures during extracorporeal membrane oxygenation were used in the French center than in both Australian centers (23.9 ± 1.4 vs 27.6 ± 3.7 and 27.8 ± 3.6; <italic>p</italic> < 0.0001). Overall ICU mortality was 29%. Lower positive end-expiratory pressure levels (until day 7) and lower delivered tidal volume after 3 days on extracorporeal membrane oxygenation were associated with significantly higher mortality (<italic>p</italic> < 0.05). In multivariate analysis, higher positive end-expiratory pressure levels during the first 3 days of extracorporeal membrane oxygenation support were associated with lower mortality (odds ratio, 0.75; 95% CI, 0.64–0.88; <italic>p</italic> = 0.0006). Other independent predictors of ICU mortality included time between ICU admission and extracorporeal membrane oxygenation initiation, plateau pressure greater than 30 cm H<sub>2</sub>O before extracorporeal membrane oxygenation initiation, and lactate level on day 3 of extracorporeal membrane oxygenation support.</p> </sec> <sec> <title>Conclusions:</title> <p>Protective mechanical ventilation strategies were routinely used in high-volume extracorporeal membrane oxygenation centers. However, higher positive end-expiratory pressure levels during the first 3 days on extracorporeal membrane oxygenation support were independently associated with improved survival. Further prospective trials on the optimal mechanical ventilation strategy during extracorporeal membrane oxygenation support are warranted.</p> </sec> </abstract>