Association of Ventilator Settings With Mortality in Pediatric Patients Treated With Extracorporeal Life Support for Respiratory Failure

Abstract

Extracorporeal life support (ECLS) is a treatment for acute respiratory failure that can provide extracorporeal gas exchange, allowing lung rest. However, while most patients remain mechanically ventilated during ECLS, there is a paucity of evidence to guide the choice of ventilator settings. We studied the associations between ventilator settings 24 hours after ECLS initiation and mortality in pediatric patients using a retrospective analysis of data from the Extracorporeal Life Support Organization Registry. 3497 patients, 29 days to 18 years of age, treated with ECLS for respiratory failure between 2015 and 2021, were included for analysis. 93.3% of patients on ECLS were ventilated with conventional mechanical ventilation. Common settings included positive end-expiratory pressure (PEEP) of 10 cm H 2 O (45.7%), delta pressure (ΔP) of 10 cm H 2 O (28.3%), rate of 10-14 breaths per minute (55.9%), and fraction of inspired oxygen (FiO 2 ) of 0.31-0.4 (30.3%). In a multivariate model, PEEP >10 cm H 2 O (versus PEEP < 8 cm H 2 O, odds ratio [OR]: 1.53, 95% CI: 1.20-1.96) and FiO 2 ≥0.45 (versus FiO 2 < 0.4; 0.45 ≤ FiO 2 < 0.6, OR: 1.31, 95% CI: 1.03-1.67 and FiO 2 ≥ 0.6, OR: 2.30; 95% CI: 1.81-2.93) were associated with higher odds of mortality. In a secondary analysis of survivors, PEEP 8-10 cm H 2 O was associated with shorter ECLS run times (versus PEEP < 8 cm H 2 O, coefficient: −1.64, 95% CI: −3.17 to −0.11), as was ΔP >16 cm H 2 O (versus ΔP < 10 cm H 2 O, coefficient: −2.72, 95% CI: −4.30 to −1.15). Our results identified several categories of ventilator settings as associated with mortality or ECLS run-time. Further studies are necessary to understand whether these results represent a causal relationship.

Pediatric Highlights From the Extracorporeal Life Support Organization Registry: 2017–2022

“…This study confirms other findings that ventilator F i O 2 is a potentially modifiable risk factor for poor outcomes in children on ECMO. 17,18 In recent years there has been much discussion and debate about awake and mobile ECMO. Kohne et al provided a foundation in this area by describing the current practice of tracheostomy in children on ECMO for respiratory indications.…”

Extracorporeal Membrane Oxygenation in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

“…However, optimal lung-protective MV, in terms of mode and ventilator settings during ECMO, remains unproven. In a multisite, retrospective observational study of 204 children supported on venovenous ECMO for acute respiratory failure, patients with a Fio 2 requirement higher than 50% at day 3 of ECMO had a significantly higher death rate (46% vs 22%; p = 0.001) than those with Fio 2 equal or less than 50% (8), and these findings were duplicated in the ELSO Registry (9,10). No significant association between ventilatory settings such as PEEP, peak pressure, driving pressure, plateau pressure, and outcomes were found.…”

“…T he 2015 Pediatric Acute Lung Injury Consensus Conference (PALICC) international recommendations on pediatric acute respiratory distress syndrome (PARDS) published 11 recommendations regarding the role of extracorporeal membrane oxygenation (ECMO) support in PARDS (1). Since 2015, there have been advances in ECMO research in adults with acute respiratory distress syndrome (ARDS) (2)(3)(4)(5)(6), devices and cannulas (7), management (8)(9)(10), and expanding indications, most notably COVID-19 (11)(12)(13).…”

What’s new in neonatal and pediatric extracorporeal membrane oxygenation in 2022–2023? Insights from the EuroELSO congress 2023

“…Currently, the correct management of the native lung during ECMO is still a matter of debate both in neonates and children. [9][10][11] Both Friedman ML et al 11 and Blauvelt DG et al 10 showed that the maintenance of high ventilator settings during ECMO (e.g. FiO 2 >60% and a PEEP >10 cmH 2 O) was associated with higher odds of mortality.…”