Abstract
BackgroundThe survival predictors and optimal mechanical ventilator settings in patients with severe acute respiratory distress syndrome (ARDS) undergoing extracorporeal membrane oxygenation (ECMO) are uncertain. This study was designed to investigate the influences of clinical variables and mechanical ventilation settings on the outcomes for severe ARDS patients receiving ECMO.MethodsWe reviewed severe ARDS patients who received ECMO due to refractory hypoxemia from May 2006 to October 2015. Serial mechanical ventilator settings before and after ECMO and factors associated with survival were analyzed.ResultsA total of 158 severe ARDS patients received ECMO were finally analyzed. Overall intensive care unit (ICU) mortality was 55.1%. After ECMO initiation, tidal volume, peak inspiratory pressure and dynamic driving pressure were decreased, while positive end-expiratory pressure levels were relative maintained. After ECMO initiation, nonsurvivors had significantly higher dynamic driving pressure until day 7 than survivors. Cox proportional hazards regression model revealed that immunocompromised [hazard ratio 1.957; 95% confidence interval (CI) 1.216–3.147; p = 0.006], Acute Physiology and Chronic Health Evaluation (APACHE) II score (hazard ratio 1.039; 95% CI 1.005–1.073; p = 0.023), ARDS duration before ECMO (hazard ratio 1.002; 95% CI 1.000–1.003; p = 0.029) and mean dynamic driving pressure from day 1 to 3 on ECMO (hazard ratio 1.070; 95% CI 1.026–1.116; p = 0.002) were independently associated with ICU mortality.ConclusionsFor severe ARDS patients receiving ECMO, immunocompromised status, APACHE II score and the duration of ARDS before ECMO initiation were significantly associated with ICU survival. Higher dynamic driving pressure during first 3 days of ECMO support was also independently associated with increased ICU mortality.
Highlights
The survival predictors and optimal mechanical ventilator settings in patients with severe acute respira‐ tory distress syndrome (ARDS) undergoing extracorporeal membrane oxygenation (ECMO) are uncertain
The present study in severe ARDS patients receiving ECMO revealed that dynamic driving pressure from day 1 to 3 on ECMO was independently associated with mortality (Table 2)
Our study found that the duration of ARDS, Acute Physiology and Chronic Health Evaluation (APACHE) II score and immunocompromised status before ECMO were independently associated with intensive care unit (ICU) mortality
Summary
The survival predictors and optimal mechanical ventilator settings in patients with severe acute respira‐ tory distress syndrome (ARDS) undergoing extracorporeal membrane oxygenation (ECMO) are uncertain. ECMO facilitates an ultra-protective ventilation of more lowering delivered tidal volume and airway pressure for resting the lungs. ECMO support limited stress and strain with ultra-protective ventilation, the specific extent of lung rest strategy and the optimal mechanical ventilation settings targets during ECMO for severe ARDS patients remained uncertain [11,12,13,14,15,16]. A recent study from 3562 patients with ARDS enrolled in 9 previous reported randomized controlled trials concluded that decreases in driving pressure were strongly associated with increased survival for patients with ARDS [17]
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