Prone positioning and extracorporeal membrane oxygenation for severe acute respiratory distress syndrome: time for a randomized trial?

Guervilly, Christophe; Prud’Homme, Eloi; Pauly, Vanessa; Bourenne, Jérémie; Hraiech, Sami; Daviet, Florence; Adda, Mélanie; Coiffard, Benjamin; Forel, Jean Marie; Roch, Antoine; Persico, Nicolas; Papazian, Laurent

doi:10.1007/s00134-019-05570-9

Cited by 61 publications

(88 citation statements)

References 4 publications

(4 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Notably, EIT-identified optimal PEEP before PP did not differ significantly between PCG+ and PCG− (P = 0.09). It was significantly reduced after PP in all patients, shifting from 14.8 (12)(13)(14)(15)(16)(17) to 11.7 (9-14) cmH 2 O for PCG+ , while PCG−, optimal PEEP declined from 12 (8-15.5) to 9 (6.5-11.5) cmH 2 O (Fig. 5).…”

Section: Eit-identified Optimal Peepmentioning

confidence: 90%

“…Although the use of PP combined with ECMO is still controversial [12], few studies have suggested that it could improve oxygenation and static compliance [13,14], thereby preventing subsequent VILI, when associated with "ultra-protective" ventilation. To date, PP physiological effects on regional ventilation and the optimal positive end-expiratory pressure (PEEP) level in this specific population with very low VT and altered static compliance are unknown.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Prone positioning monitored by electrical impedance tomography in patients with severe acute respiratory distress syndrome on veno-venous ECMO

Franchineau

Bréchot

Hékimian

et al. 2020

Ann. Intensive Care

View full text Add to dashboard Cite

Background: Prone positioning (PP) during veno-venous ECMO is feasible, but its physiological effects have never been thoroughly evaluated. Our objectives were to describe, through electrical impedance tomography (EIT), the impact of PP on global and regional ventilation, and optimal PEEP level. Methods:A monocentric study conducted on ECMO-supported severe ARDS patients, ventilated in pressurecontrolled mode, with 14-cmH 2 O driving pressure and EIT-based "optimal PEEP". Before, during and after a 16-h PP session, EIT-based distribution and variation of tidal impedance, VT dorsal /VT global ratio, end-expiratory lung impedance (EELI) and static compliance were collected. Subgroup analyses were performed in patients who increased their static compliance by ≥ 3 mL/cmH 2 O after 16 h of PP.Results: For all patients (n = 21), tidal volume and EELI were redistributed from ventral to dorsal regions during PP. EIT-based optimal PEEP was significantly lower in PP than in supine position. Median (IQR) optimal PEEP decreased from 14 (12-16) to 10 (8-14) cmH 2 O. Thirteen (62%) patients increased their static compliance by ≥ 3 mL/cmH 2 O after PP on ECMO. This subgroup had higher body mass index, more frequent viral pneumonia, shorter ECMO duration, and lower baseline VT dorsal /VT global ratio than patients with compliance ≤ 3 mL/cmH 2 O (P < 0.01). Conclusion:Although baseline tidal volume distribution on EIT may predict static compliance improvement after PP on ECMO, our results support physiological benefits of PP in all ECMO patients, by modifying lung mechanics and potentially reducing VILI. Further studies, including a randomized-controlled trial, are now warranted to confirm potential PP benefits during ECMO.

show abstract

Section: Eit-identified Optimal Peepmentioning

confidence: 90%

Section: Introductionmentioning

confidence: 99%

Prone positioning monitored by electrical impedance tomography in patients with severe acute respiratory distress syndrome on veno-venous ECMO

Franchineau

Bréchot

Hékimian

et al. 2020

Ann. Intensive Care

View full text Add to dashboard Cite

show abstract

“…Prone positioning could be considered during ECMO, although there are few data to support this practice. 38 The benefits of ECMO for ARDS largely stem from its ability to confer lung protection, which is associated with decreased adverse outcomes. It should be noted that although extracorporeal CO 2 removal for lung-protective ventilation is feasible, it is neither evidence-based nor is it universally available.…”

Section: Quality Assurance and Collaborative Researchmentioning

confidence: 99%

Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases

Ramanathan

Antognini

Combes

et al. 2020

The Lancet Respiratory Medicine

493

470

View full text Add to dashboard Cite

“…First, individualization of PEEP during ECMO using transpulmonary pressure measurements [ 60 ] or electrical impedance tomography (EIT) [ 61 ] appear promising. Second, some centers currently perform prone positioning during ECMO with a goal of reducing VILI [ 41 , 62 ]. Two recent retrospective series of severe ARDS patients showed that prone positioning, while on-ECMO demonstrated higher ECMO-weaning and survival rates [ 62 , 63 ].…”

Section: Specific Management During Vv-ecmomentioning

confidence: 99%

Extracorporeal life support for adults with acute respiratory distress syndrome

et al. 2020

View full text Add to dashboard Cite

Extracorporeal life support (ECLS) can support gas exchange in patients with the acute respiratory distress syndrome (ARDS). During ECLS, venous blood is drained from a central vein via a cannula, pumped through a semipermeable membrane that permits diffusion of oxygen and carbon dioxide, and returned via a cannula to a central vein. Two related forms of ECLS are used. Venovenous extracorporeal membrane oxygenation (ECMO), which uses high blood flow rates to both oxygenate the blood and remove carbon dioxide, may be considered in patients with severe ARDS whose oxygenation or ventilation cannot be maintained adequately with best practice conventional mechanical ventilation and adjunctive therapies, including prone positioning. Extracorporeal carbon dioxide removal (ECCO 2 R) uses lower blood flow rates through smaller cannulae and provides substantial CO 2 elimination (~ 20–70% of total CO 2 production), albeit with marginal improvement in oxygenation. The rationale for using ECCO 2 R in ARDS is to facilitate lung-protective ventilation by allowing a reduction of tidal volume, respiratory rate, plateau pressure, driving pressure and mechanical power delivered by the mechanical ventilator. This narrative review summarizes physiological concepts related to ECLS, as well as the rationale and evidence supporting ECMO and ECCO 2 R for the treatment of ARDS. It also reviews complications, limitations, and the ethical dilemmas that can arise in treating patients with ECLS. Finally, it discusses future key research questions and challenges for this technology.

show abstract

Prone positioning and extracorporeal membrane oxygenation for severe acute respiratory distress syndrome: time for a randomized trial?

Cited by 61 publications

References 4 publications

Prone positioning monitored by electrical impedance tomography in patients with severe acute respiratory distress syndrome on veno-venous ECMO

Prone positioning monitored by electrical impedance tomography in patients with severe acute respiratory distress syndrome on veno-venous ECMO

Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases

Extracorporeal life support for adults with acute respiratory distress syndrome

Contact Info

Product

Resources

About