Optimal positive end-expiratory pressure reduces right ventricular dysfunction in COVID-19 patients on venovenous extracorporeal membrane oxygenation: A retrospective single-center study

Right ventricular injury definition and management in patients with severe respiratory failure receiving veno-venous extracorporeal membrane oxygenation: a scoping review

“…One study assessed the effect of an optimal PEEP strategy using esophageal manometry (PEEP set to an endexpiratory transpulmonary pressure of 0-3 cm H 2 O) compared to setting the standard PEEP to 10 cmH 2 O, throughout the duration of VV ECMO support. Though the driving pressure was similar between two groups, the optimal PEEP group had reduced rates of hemodynamically signi cant RV dysfunction (4.5% vs. 44.0%, p = 0.0001) and higher rates of survival to liberation from ECMO support (72.7% vs. 44.0%, p = 0.022) [14]. Our systematic search did not identify any studies investigating the effect of prone positioning on RV biomechanics in patients with evidence of RV injury during VV ECMO support.…”

“…Thirteen studies (43.3%) reported on RV injury management strategies [11, 13-18, 30-33, 36, 37] but only four studies (12.9%) reported on the effect of interventions on hemodynamics and indices of RV biomechanics [14,16,31,36]. Interventions identi ed included: VP ECMO (single-site dual lumen or dual-site single lumen cannulation), or mode conversion from VV to VP ECMO), veno-arterial (VA) ECMO, inodilator agents (milrinone and dobutamine), pulmonary vasodilators, ultra-lung-protective ventilation targeting a driving pressure level of 10 cmH 2 O, and optimization of positive end-expiratory pressure (PEEP) using esophageal manometry.…”

“…Pilot studies investigating ultra-lung-protective ventilation, a strategy that achieves low driving pressure, tidal volume, and mechanical power during VV ECMO or extracorporeal carbon dioxide removal, showed mixed results on its impact on RV dimensions and function [36,54]. Only one study targeted 'optimal' PEEP guided by transpulmonary pressure, resulting in lower rates of hemodynamically signi cant RV injury and improved survival to liberation from ECMO [14]. A similar result was reported in a study, which investigated the effect of three PEEP titration methods on echocardiographic measures of RV injury (including Tei index, TAPSE, RV FAC, and RVEDA/LVEDA) in 62 patients with ARDS [55].…”

Right ventricular injury definition and management in patients with severe respiratory failure receiving veno-venous extracorporeal membrane oxygenation: a scoping review

“…One study assessed the effect of an optimal PEEP strategy using esophageal manometry (PEEP set to an endexpiratory transpulmonary pressure of 0-3 cm H 2 O) compared to setting the standard PEEP to 10 cmH 2 O, throughout the duration of VV ECMO support. Though the driving pressure was similar between two groups, the optimal PEEP group had reduced rates of hemodynamically signi cant RV dysfunction (4.5% vs. 44.0%, p = 0.0001) and higher rates of survival to liberation from ECMO support (72.7% vs. 44.0%, p = 0.022) [14]. Our systematic search did not identify any studies investigating the effect of prone positioning on RV biomechanics in patients with evidence of RV injury during VV ECMO support.…”

“…Thirteen studies (43.3%) reported on RV injury management strategies [11, 13-18, 30-33, 36, 37] but only four studies (12.9%) reported on the effect of interventions on hemodynamics and indices of RV biomechanics [14,16,31,36]. Interventions identi ed included: VP ECMO (single-site dual lumen or dual-site single lumen cannulation), or mode conversion from VV to VP ECMO), veno-arterial (VA) ECMO, inodilator agents (milrinone and dobutamine), pulmonary vasodilators, ultra-lung-protective ventilation targeting a driving pressure level of 10 cmH 2 O, and optimization of positive end-expiratory pressure (PEEP) using esophageal manometry.…”

“…Pilot studies investigating ultra-lung-protective ventilation, a strategy that achieves low driving pressure, tidal volume, and mechanical power during VV ECMO or extracorporeal carbon dioxide removal, showed mixed results on its impact on RV dimensions and function [36,54]. Only one study targeted 'optimal' PEEP guided by transpulmonary pressure, resulting in lower rates of hemodynamically signi cant RV injury and improved survival to liberation from ECMO [14]. A similar result was reported in a study, which investigated the effect of three PEEP titration methods on echocardiographic measures of RV injury (including Tei index, TAPSE, RV FAC, and RVEDA/LVEDA) in 62 patients with ARDS [55].…”

Association Between Positive End-Expiratory Pressure at Venovenous Extracorporeal Membrane Oxygenation Initiation and Liberation Outcomes in Acute Respiratory Distress Syndrome: A Multicenter Retrospective Study

“…Our findings align with prior studies reporting that lower PEEP during venovenous ECMO is associated with worse outcomes. Schmidt et al ( 7 ) found that lower PEEP in the first 3 days of ECMO was independently linked to higher ICU mortality, while Estoos et al ( 18 ) showed that an esophageal manometry-guided higher PEEP strategy reduced right ventricular dysfunction and improved decannulation in COVID-19 ARDS. Compared with these studies, our work adds strength by analyzing a larger, multicenter cohort with broader adjustment for confounders, including ARDS etiology, lung injury severity, and KL-6.…”

Pathophysiology and management of right ventricular failure in critically ill patients: A narrative review

“…, in patients with ARDS) will be more sensitive to changes in PEEP and tidal volume than those with greater or normal lung compliance. Where possible, consider using esophageal manometry in combination with PA-derived hemodynamics to optimally titrate PEEP[ 82 ].…”

Right ventricular injury definition and management in patients with severe respiratory failure receiving veno-venous extracorporeal membrane oxygenation: a scoping review

“…One study assessed the effect of an optimal PEEP strategy using esophageal manometry (PEEP set to an endexpiratory transpulmonary pressure of 0-3 cm H 2 O) compared to setting the standard PEEP to 10 cmH 2 O, throughout the duration of VV ECMO support. Though the driving pressure was similar between two groups, the optimal PEEP group had reduced rates of hemodynamically signi cant RV dysfunction (4.5% vs. 44.0%, p = 0.0001) and higher rates of survival to liberation from ECMO support (72.7% vs. 44.0%, p = 0.022) [14]. Our systematic search did not identify any studies investigating the effect of prone positioning on RV biomechanics in patients with evidence of RV injury during VV ECMO support.…”

“…Thirteen studies (43.3%) reported on RV injury management strategies [11, 13-18, 30-33, 36, 37] but only four studies (12.9%) reported on the effect of interventions on hemodynamics and indices of RV biomechanics [14,16,31,36]. Interventions identi ed included: VP ECMO (single-site dual lumen or dual-site single lumen cannulation), or mode conversion from VV to VP ECMO), veno-arterial (VA) ECMO, inodilator agents (milrinone and dobutamine), pulmonary vasodilators, ultra-lung-protective ventilation targeting a driving pressure level of 10 cmH 2 O, and optimization of positive end-expiratory pressure (PEEP) using esophageal manometry.…”

“…Pilot studies investigating ultra-lung-protective ventilation, a strategy that achieves low driving pressure, tidal volume, and mechanical power during VV ECMO or extracorporeal carbon dioxide removal, showed mixed results on its impact on RV dimensions and function [36,54]. Only one study targeted 'optimal' PEEP guided by transpulmonary pressure, resulting in lower rates of hemodynamically signi cant RV injury and improved survival to liberation from ECMO [14]. A similar result was reported in a study, which investigated the effect of three PEEP titration methods on echocardiographic measures of RV injury (including Tei index, TAPSE, RV FAC, and RVEDA/LVEDA) in 62 patients with ARDS [55].…”

Association Between Positive End-Expiratory Pressure at Venovenous Extracorporeal Membrane Oxygenation Initiation and Liberation Outcomes in Acute Respiratory Distress Syndrome: A Multicenter Retrospective Study

“…Our findings align with prior studies reporting that lower PEEP during venovenous ECMO is associated with worse outcomes. Schmidt et al ( 7 ) found that lower PEEP in the first 3 days of ECMO was independently linked to higher ICU mortality, while Estoos et al ( 18 ) showed that an esophageal manometry-guided higher PEEP strategy reduced right ventricular dysfunction and improved decannulation in COVID-19 ARDS. Compared with these studies, our work adds strength by analyzing a larger, multicenter cohort with broader adjustment for confounders, including ARDS etiology, lung injury severity, and KL-6.…”

Pathophysiology and management of right ventricular failure in critically ill patients: A narrative review

“…, in patients with ARDS) will be more sensitive to changes in PEEP and tidal volume than those with greater or normal lung compliance. Where possible, consider using esophageal manometry in combination with PA-derived hemodynamics to optimally titrate PEEP[ 82 ].…”

Right ventricular injury definition and management in patients with severe respiratory failure receiving veno-venous extracorporeal membrane oxygenation: a scoping review

“…One study assessed the effect of an optimal PEEP strategy using esophageal manometry (PEEP set to an endexpiratory transpulmonary pressure of 0-3 cm H 2 O) compared to setting the standard PEEP to 10 cmH 2 O, throughout the duration of VV ECMO support. Though the driving pressure was similar between two groups, the optimal PEEP group had reduced rates of hemodynamically signi cant RV dysfunction (4.5% vs. 44.0%, p = 0.0001) and higher rates of survival to liberation from ECMO support (72.7% vs. 44.0%, p = 0.022) [14]. Our systematic search did not identify any studies investigating the effect of prone positioning on RV biomechanics in patients with evidence of RV injury during VV ECMO support.…”

“…Thirteen studies (43.3%) reported on RV injury management strategies [11, 13-18, 30-33, 36, 37] but only four studies (12.9%) reported on the effect of interventions on hemodynamics and indices of RV biomechanics [14,16,31,36]. Interventions identi ed included: VP ECMO (single-site dual lumen or dual-site single lumen cannulation), or mode conversion from VV to VP ECMO), veno-arterial (VA) ECMO, inodilator agents (milrinone and dobutamine), pulmonary vasodilators, ultra-lung-protective ventilation targeting a driving pressure level of 10 cmH 2 O, and optimization of positive end-expiratory pressure (PEEP) using esophageal manometry.…”

“…Pilot studies investigating ultra-lung-protective ventilation, a strategy that achieves low driving pressure, tidal volume, and mechanical power during VV ECMO or extracorporeal carbon dioxide removal, showed mixed results on its impact on RV dimensions and function [36,54]. Only one study targeted 'optimal' PEEP guided by transpulmonary pressure, resulting in lower rates of hemodynamically signi cant RV injury and improved survival to liberation from ECMO [14]. A similar result was reported in a study, which investigated the effect of three PEEP titration methods on echocardiographic measures of RV injury (including Tei index, TAPSE, RV FAC, and RVEDA/LVEDA) in 62 patients with ARDS [55].…”

Association Between Positive End-Expiratory Pressure at Venovenous Extracorporeal Membrane Oxygenation Initiation and Liberation Outcomes in Acute Respiratory Distress Syndrome: A Multicenter Retrospective Study

“…Our findings align with prior studies reporting that lower PEEP during venovenous ECMO is associated with worse outcomes. Schmidt et al ( 7 ) found that lower PEEP in the first 3 days of ECMO was independently linked to higher ICU mortality, while Estoos et al ( 18 ) showed that an esophageal manometry-guided higher PEEP strategy reduced right ventricular dysfunction and improved decannulation in COVID-19 ARDS. Compared with these studies, our work adds strength by analyzing a larger, multicenter cohort with broader adjustment for confounders, including ARDS etiology, lung injury severity, and KL-6.…”

Pathophysiology and management of right ventricular failure in critically ill patients: A narrative review

“…, in patients with ARDS) will be more sensitive to changes in PEEP and tidal volume than those with greater or normal lung compliance. Where possible, consider using esophageal manometry in combination with PA-derived hemodynamics to optimally titrate PEEP[ 82 ].…”