Page 1 of 11
AJRCCM Articles in Press. Published on 01-July-2015 as 10.1164/rccm.201504-0755RR
Beyond the Blue: Extracorporeal Life Support (ECLS)
Ghislaine Douflé, MD; Francesca Facchin, MD; and Eddy Fan, MD, PhD
From the Interdepartmental Division of Critical Care Medicine, University of Toronto, and the Extracorporeal Life Support Program, Toronto General Hospital, Toronto, Canada
Recommended reading from the Extracorporeal Life Support Program, Toronto General Hospital; Eddy Fan, MD, PhD, Medical Director and Supervising Author
Corresponding Author Eddy Fan, MD, PhD Toronto General Hospital 585 University Avenue, PMB 11-123 Toronto, Ontario, Canada M5G 2N2 Tel: (416) 340-4800 ext. 5061 Fax: (647) 776-3148 Email: [email protected]
Word count: 544 + 530 + 489 (manuscript text only)
Keywords: extracorporeal membrane oxygenation; intensive care units; outcomes; respiratory distress syndrome, adult
1 Copyright © 2015 by the American Thoracic Society
AJRCCM Articles in Press. Published on 01-July-2015 as 10.1164/rccm.201504-0755RR
Page 2 of 11
Schmidt M, et al.; Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Critical Care medicine
Recent data suggest that further limiting tidal volume and plateau pressure to deliver “ultraprotective ventilation” in moderate-severe ARDS patients supported with extracorporeal membrane oxygenation (ECMO) might be beneficial (1). Indeed, a number of proof of concept studies have suggested that using extracorporeal support to facilitate a reduction in the intensity of mechanical ventilation (MV) may be associated with an improvement in a number of surrogate outcomes (1, 2). However, these results are hypothesis-generating, our knowledge regarding the optimal ventilatory setting in these patients is limited, and the choice between a lung protective strategy and a total lung rest strategy remains controversial (3, 4).
Schmidt and colleagues have tried to fill this gap by analyzing the MV settings applied during ECMO in 3 centers (Melbourne, Sydney, and Paris) (5). They retrospectively analyzed 168 patients (2007-2013) supported with venovenous (VV) ECMO, focusing on the potential impact of plateau pressure, tidal volume and PEEP on ICU mortality. While there were many differences between countries, it is interesting to notice that the majority of patients on ECMO received pressure-targeted modes with lower median plateau pressure (26 cmH2O, reduced from 32 cmH2O) and tidal volume (3.9 ± 1.6, reduced from 6.3 ± 1.5) as compared to the period before ECMO; conversely, PEEP was similar before and after initiation of ECMO (13 ± 4 vs. 12 ± 3). There was no significant difference
2 Copyright © 2015 by the American Thoracic Society
AJRCCM Articles in Press. Published on 01-July-2015 as 10.1164/rccm.201504-0755RR
Page 3 of 11
between centers in the duration of ECMO (median 10 days [IQR 6-18]), ICU stay (median 28 days [IQR 16-42]), or overall mortality (29%). Using multivariate logistic regression, length of ICU stay before ECMO, plateau pressure >30 cmH2O, lower PEEP levels, and lactate levels were found independent predictors of ICU mortality.
This is the first study to evaluate MV settings and outcomes in a large cohort of ARDS patients supported with ECMO. The results suggest that patients treated with ECMO would benefit of higher PEEP during both conventional ventilation and the initial ECMO period, showing the importance of prevention of cyclic end-expiratory collapse during MV, reducing atelectrauma. Importantly, the association between plateau pressure > 30 cmH2O and increased mortality confirm the importance of the using a lung protective strategy in ECMO patients. However, this study has a number of important limitations. The study was conducted in 3 large academic ECMO centers, limiting generalizability. By only selecting variables with a univariate p-value
AJRCCM Articles in Press. Published on 01-July-2015 as 10.1164/rccm.201504-0755RR
Beyond the Blue: Extracorporeal Life Support (ECLS)
Ghislaine Douflé, MD; Francesca Facchin, MD; and Eddy Fan, MD, PhD
From the Interdepartmental Division of Critical Care Medicine, University of Toronto, and the Extracorporeal Life Support Program, Toronto General Hospital, Toronto, Canada
Recommended reading from the Extracorporeal Life Support Program, Toronto General Hospital; Eddy Fan, MD, PhD, Medical Director and Supervising Author
Corresponding Author Eddy Fan, MD, PhD Toronto General Hospital 585 University Avenue, PMB 11-123 Toronto, Ontario, Canada M5G 2N2 Tel: (416) 340-4800 ext. 5061 Fax: (647) 776-3148 Email: [email protected]
Word count: 544 + 530 + 489 (manuscript text only)
Keywords: extracorporeal membrane oxygenation; intensive care units; outcomes; respiratory distress syndrome, adult
1 Copyright © 2015 by the American Thoracic Society
AJRCCM Articles in Press. Published on 01-July-2015 as 10.1164/rccm.201504-0755RR
Page 2 of 11
Schmidt M, et al.; Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Critical Care medicine
Recent data suggest that further limiting tidal volume and plateau pressure to deliver “ultraprotective ventilation” in moderate-severe ARDS patients supported with extracorporeal membrane oxygenation (ECMO) might be beneficial (1). Indeed, a number of proof of concept studies have suggested that using extracorporeal support to facilitate a reduction in the intensity of mechanical ventilation (MV) may be associated with an improvement in a number of surrogate outcomes (1, 2). However, these results are hypothesis-generating, our knowledge regarding the optimal ventilatory setting in these patients is limited, and the choice between a lung protective strategy and a total lung rest strategy remains controversial (3, 4).
Schmidt and colleagues have tried to fill this gap by analyzing the MV settings applied during ECMO in 3 centers (Melbourne, Sydney, and Paris) (5). They retrospectively analyzed 168 patients (2007-2013) supported with venovenous (VV) ECMO, focusing on the potential impact of plateau pressure, tidal volume and PEEP on ICU mortality. While there were many differences between countries, it is interesting to notice that the majority of patients on ECMO received pressure-targeted modes with lower median plateau pressure (26 cmH2O, reduced from 32 cmH2O) and tidal volume (3.9 ± 1.6, reduced from 6.3 ± 1.5) as compared to the period before ECMO; conversely, PEEP was similar before and after initiation of ECMO (13 ± 4 vs. 12 ± 3). There was no significant difference
2 Copyright © 2015 by the American Thoracic Society
AJRCCM Articles in Press. Published on 01-July-2015 as 10.1164/rccm.201504-0755RR
Page 3 of 11
between centers in the duration of ECMO (median 10 days [IQR 6-18]), ICU stay (median 28 days [IQR 16-42]), or overall mortality (29%). Using multivariate logistic regression, length of ICU stay before ECMO, plateau pressure >30 cmH2O, lower PEEP levels, and lactate levels were found independent predictors of ICU mortality.
This is the first study to evaluate MV settings and outcomes in a large cohort of ARDS patients supported with ECMO. The results suggest that patients treated with ECMO would benefit of higher PEEP during both conventional ventilation and the initial ECMO period, showing the importance of prevention of cyclic end-expiratory collapse during MV, reducing atelectrauma. Importantly, the association between plateau pressure > 30 cmH2O and increased mortality confirm the importance of the using a lung protective strategy in ECMO patients. However, this study has a number of important limitations. The study was conducted in 3 large academic ECMO centers, limiting generalizability. By only selecting variables with a univariate p-value
