A prospective, multicenter, randomized study of high versus low positive end-expiratory pressure during extracorporeal membrane oxygenation

Keszler, Martin; Ryckman, Frederick C.; McDonald, John V.; Sweet, L D; Moront, Michael G.; Boegli, Marianne J.; Cox, Cynthia; Leftridge, Clifton A.

doi:10.1016/s0022-3476(05)80612-2

Cited by 61 publications

(19 citation statements)

References 20 publications

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“…Although numerous approaches have been employed to improve the effects of ventilation [1-3], including protective ventilator setting strategies and paralytic agents, the reported mortality rate of ARDS patients continues to be as high as 40% [4]. The high resource consumption associated with this severe disease results in a heavy burden to society.…”

Section: Introductionmentioning

confidence: 99%

The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials

Pan

et al. 2014

Crit Care

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IntroductionProne positioning (PP) has been reported to improve the survival of patients with severe acute respiratory distress syndrome (ARDS). However, it is uncertain whether the beneficial effects of PP are associated with positive end-expiratory pressure (PEEP) levels and long durations of PP. In this meta-analysis, we aimed to evaluate whether the effects of PP on mortality could be affected by PEEP level and PP duration and to identify which patients might benefit the most from PP.MethodsPublications describing randomized controlled trials (RCTs) in which investigators have compared prone and supine ventilation were retrieved by searching the following electronic databases: PubMed/MEDLINE, the Cochrane Library, the Web of Science and Elsevier Science (inception to May 2013). Two investigators independently selected RCTs and assessed their quality. The data extracted from the RCTs were combined in a cumulative meta-analysis and analyzed using methods recommended by the Cochrane Collaboration.ResultsA total of nine RCTs with an aggregate of 2,242 patients were included. All of the studies received scores of up to three points using the methods recommended by Jadad et al. One trial did not conceal allocation. This meta-analysis revealed that, compared with supine positioning, PP decreased the 28- to 30-day mortality of ARDS patients with a ratio of partial pressure of arterial oxygen/fraction of inspired oxygen ≤100 mmHg (n = 508, risk ratio (RR) = 0.71, 95 confidence interval (CI) = 0.57 to 0.89; P = 0.003). PP was shown to reduce both 60-day mortality (n = 518, RR = 0.82, 95% CI = 0.68 to 0.99; P = 0.04) and 90-day mortality (n = 516, RR = 0.57, 95% CI = 0.43 to 0.75; P < 0.0001) in ARDS patients ventilated with PEEP ≥10 cmH2O. Moreover, PP reduced 28- to 30-day mortality when the PP duration was >12 h/day (n = 1,067, RR = 0.73, 95% CI = 0.54 to 0.99; P = 0.04).ConclusionsPP reduced mortality among patients with severe ARDS and patients receiving relatively high PEEP levels. Moreover, long-term PP improved the survival of ARDS patients.

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Section: Introductionmentioning

confidence: 99%

The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials

Pan

et al. 2014

Crit Care

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Section: Discussionmentioning

confidence: 99%

“…Strategies to facilitate increased FRC in infants receiving ECLS include exogenous surfactant replacement therapy and the delivery of high-end expiratory pressure. 14,15 PLV has been demonstrated to be an effective technique for lung volume recruitment and pulmonary recovery in numerous animal models of ARDS.PLV has been shown to be very effective in improving lung function and in many different animal models with respiratory failure. Perfluorochemicals are inert liquids generated by replacing the carbon-bound hydrogen atoms on organic compounds with fluorine.…”

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confidence: 99%

“…12,13 Therapy for infants receiving ECLS could be optimized through effective recruitment of available lung parenchyma, increasing lung compliance, and removal of lung debris. [12][13][14][15] Partial liquid ventilation (PLV) is a technique wherein the lung is slowly filled with a perfluorochemical, and ventilation is maintained with conventional gas ventilation of the liquid-filled lung. [3][4][5][6][7]16 Clinical investigations designed to test the safety and efficacy of PLV with perflubron in humans are now underway.…”

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Partial Liquid Ventilation in Critically Ill Infants Receiving Extracorporeal Life Support

et al. 1997

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ABSTRACT. Objectives. To demonstrate that a period of partial liquid ventilation (PLV) with perflubron improves pulmonary function, without adverse events, in a select group of critically ill infants receiving extracorporeal life support (ECLS) with a high likelihood of mortality.Methods. This was an open-label, noncontrolled, phase I and II trial of PLV in two infants with congenital diaphragmatic hernia and four infants with acute respiratory distress syndrome (ARDS) who were failing to improve while receiving ECLS. PLV was performed by instilling and maintaining a functional residual capacity of sterile perflubron for 4 to 96 hours.Results. Four infants were successfully weaned off ECLS for at least 3 days, and two infants (both with ARDS) are long-term survivors after PLV. All infants demonstrated lung recruitment and improved lung compliance, and there were no adverse events related to PLV.Conclusions. The study suggests that perflubron PLV is safe, improves lung function, and recruits lung volume in critically ill infants receiving ECLS. PLV therapy for infants with ARDS seems to have a great deal of promise. Based on this and other phase I and II trials, studies of PLV on selected full-term infants before ECLS have been initiated. Pediatrics 1997;99(1). URL: http://www. pediatrics.org/cgi/content/full/99/1/e2; congenital diaphragmatic hernia, acute respiratory distress syndrome, partial liquid ventilation, extracorporeal life support.ABBREVIATIONS. ECLS, extracorporeal life support; ARDS, acute respiratory distress syndrome; CDH, congenital diaphragmatic hernia; PLV, partial liquid ventilation; FRC, functional residual capacity.Perfluorochemicals have been explored as respiratory media for more than 20 years in many animal models of respiratory disease and, more recently, in initial phase I and II human trials of liquid ventilation.1-7 These chemicals are very stable, have low surface tension, are generally insoluble in water or lipid, and are excellent solvents for respiratory gases. The effectiveness of liquid ventilation is achieved, in part, through recruitment of collapsed gas-exchanging units, increasing lung compliance, and cleansing the lung of pulmonary debris. Sterile perflubron (LiquiVent; Alliance Pharmaceutical Corp, San Diego, CA), is one of very few perfluorochemicals that is produced as a medical-grade drug. The compound has an impressive biocompatibility profile in animals and humans and is the only fluid that is approved by the Federal Food and Drug Administration for testing as a breathing agent. Perflubron has a high solubility for respiratory gases, a positive spreading coefficient on saline, and a low viscosity and is highly radiopaque on plain radiograph or computed tomographic imaging. 8,9 Recent advances in respiratory therapies for the critically ill neonates have expanded the treatment options for infants with severe respiratory failure. In those severely effected infants, extracorporeal life support (ECLS) may result in increased survival. Nevertheless, morbidity remains high, ...

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“…Basic settings include an FiO 2 weaned to <40%, a respiratory rate set at 6-10 breaths/min, the peak inspiratory pressure < 20-25% cm H 2 O, and a PEEP of 10-14 cm H 2 O. High PEEP settings have demonstrated better lung compliance in the first 72 h, which has resulted in a shorter course of ECMO support (3,63). Systemic perfusion and intravascular volume should be maintained.…”

Section: Patient Managementmentioning

confidence: 99%

Pediatric Extracorporeal Membrane Oxygenation: An Introduction for Emergency Medicine Physicians

Gehrmann¹,

Hafner

Montgomery

et al. 2015

The Journal of Emergency Medicine

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A prospective, multicenter, randomized study of high versus low positive end-expiratory pressure during extracorporeal membrane oxygenation

Cited by 61 publications

References 20 publications

The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials

The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials

Partial Liquid Ventilation in Critically Ill Infants Receiving Extracorporeal Life Support

Pediatric Extracorporeal Membrane Oxygenation: An Introduction for Emergency Medicine Physicians

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