Mechanical Power during Veno-Venous Extracorporeal Membrane Oxygenation Initiation: A Pilot-Study

Belliato, Mirko; Epis, Francesco; Cremascoli, Luca; Ferrari, Fiorenza; Quattrone, Maria Giovanna; Fisser, Christoph; Malfertheiner, Maximilian; Taccone, Fabio Silvio; Nardo, Matteo Di; Broman, Lars Mikael; Lorusso, Roberto

doi:10.3390/membranes11010030

“…Only a few studies addressed this issue, with conflicting results. While Chiu et al reported a significant association between MP in the early phase of ECMO and mortality [ 50 ], Belliato et al [ 51 ] and Schmidt et al [ 21 ], did not report such an association. Therefore, it is possible that under VV-ECMO, DP may be more discriminant than MP to track ongoing VILI.…”

Section: Discussionmentioning

confidence: 99%

Retrospective analysis of factors associated with outcome in veno-venous extra-corporeal membrane oxygenation

Orthmann

¹

,

Ltaief²,

Bonnemain³

et al. 2023

BMC Pulm Med

0

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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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“…Studies on the clinical implications of MP were currently all observational. Some studies showed a good correlation between MP and mortality [ 21 , 22 ], whereas some did not [ 23 , 24 ]. Still, some studies barely established a correlation by modifying the definition of MP calculated [ 4 , 25 ].…”

Section: Discussionmentioning

confidence: 99%

Accuracy of calculating mechanical power of ventilation by one commonly used equation

Wu

¹

,

Kor

²

,

Mao

³

et al. 2022

J Clin Monit Comput

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Gattinoni’s equation, $${\text{MP}}_{{{\text{rs}}}} \, = \,0.098\, \times \,{\text{RR}}\, \times \,\left[ {{\text{V}}_{T} ^{2} \left( {\frac{1}{2}{\text{E}}_{{{\text{rs}}}} \, + \,{\text{RR}}\, \times \,\frac{{1\, + \,I:E}}{{60\, \times \,I:E}}\, \times \,{\text{R}}_{{{\text{aw}}}} } \right)\, + \,{\text{V}}_{{\text{T}}} \, \times \,{\text{PEEP}}} \right]$$ MP rs = 0.098 × RR × V T 2 1 2 E rs + RR × 1 + I : E 60 × I : E × R aw + V T × PEEP , now commonly used to calculate the mechanical power (MP) of ventilation. However, it calculates only inspiratory MP. In addition, the inclusion of PEEP in Gattinoni’s equation raises debate because PEEP does not produce net displacement or contribute to MP. Measuring the area within the pressure–volume loop accurately reflects the MP received in a whole ventilation cycle and the MP thus obtained is not influenced by PEEP. The MP of 25 invasively ventilated patients were calculated by Gattinoni’s equation and measured by integration of the areas within the pressure–volume loops of the ventilation cycles. The MP obtained from both methods were compared. The effects of PEEPs on MP were also evaluated. We found that the MP obtained from both methods were correlated by R2 = 0.75 and 0.66 at PEEP 5 and 10 cmH2O, respectively. The biases of the two methods were 3.13 (2.03 to 4.23) J/min (P < 0.0001) and − 1.23 (− 2.22 to − 0.24) J/min (P = 0.02) at PEEP 5 and 10 cmH2O, respectively. These P values suggested that both methods were significantly incongruent. When the tidal volume used was 6 ml/Kg, the MP by Gattinoni’s equation at PEEP 5 and 10 cmH2O were significantly different (4.51 vs 7.21 J/min, P < 0.001), but the MP by PV loop area was not influenced by PEEPs (6.46 vs 6.47 J/min, P = 0.331). Similar results were observed across all tidal volumes. We conclude that the Gattinoni’s equation is not accurate in calculating the MP of a whole ventilatory cycle and is significantly influenced by PEEP, which theoretically does not contribute to MP.

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“…Higher mechanical power while on VV‐ECMO has been demonstrated to be associated with a higher 30‐day and in‐hospital mortality as well as lower 60‐day ventilator‐free days [54, 58]. Another study did not demonstrate any association between mechanical power and ICU survival [59], but this study was limited by a small sample size and may not have been appropriately powered to detect an effect [59]. Future studies investigating mechanical power during VV‐ECMO should perhaps be enriched with patients whose lungs are being ventilated with the aforementioned settings to better elucidate the relationship between mechanical power and outcomes in ARDS patients receiving VV‐ECMO.…”

Section: Mechanical Powermentioning

confidence: 99%

Invasive mechanical ventilation in patients with acute respiratory distress syndrome receiving extracorporeal support: a narrative review of strategies to mitigate lung injury

Zochios

¹

,

Brodie

²

,

Shekar

³

et al. 2022

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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 lungprotective 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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Mechanical Power during Veno-Venous Extracorporeal Membrane Oxygenation Initiation: A Pilot-Study

Cited by 10 publications

References 58 publications

Retrospective analysis of factors associated with outcome in veno-venous extra-corporeal membrane oxygenation

Retrospective analysis of factors associated with outcome in veno-venous extra-corporeal membrane oxygenation

Accuracy of calculating mechanical power of ventilation by one commonly used equation

Invasive mechanical ventilation in patients with acute respiratory distress syndrome receiving extracorporeal support: a narrative review of strategies to mitigate lung injury

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