Mechanical Power during Veno-Venous Extracorporeal Membrane Oxygenation Initiation: A Pilot-Study.

Mirko Belliato,Matteo Di Nardo,Roberto Lorusso,Lars Mikael Broman,Francesco Epis,Maria Giovanna Quattrone,Luca Cremascoli,Christoph Fisser,Fiorenza Ferrari,Fabio Silvio Taccone,Maximilian Valentin Malfertheiner

doi:10.3390/membranes11010030

Abstract

Mechanical power (MP) represents a useful parameter to describe and quantify the forces applied to the lungs during mechanical ventilation (MV). In this multi-center, prospective, observational study, we analyzed MP variations following MV adjustments after veno-venous extra-corporeal membrane oxygenation (VV ECMO) initiation. We also investigated whether the MV parameters (including MP) in the early phases of VV ECMO run may be related to the intensive care unit (ICU) mortality. Thirty-five patients with severe acute respiratory distress syndrome were prospectively enrolled and analyzed. After VV ECMO initiation, we observed a significant decrease in median MP (32.4 vs. 8.2 J/min, p < 0.001), plateau pressure (27 vs. 21 cmH2O, p = 0.012), driving pressure (11 vs. 8 cmH2O, p = 0.014), respiratory rate (RR, 22 vs. 14 breaths/min, p < 0.001), and tidal volume adjusted to patient ideal body weight (VT/IBW, 5.5 vs. 4.0 mL/kg, p = 0.001) values. During the early phase of ECMO run, RR (17 vs. 13 breaths/min, p = 0.003) was significantly higher, while positive end-expiratory pressure (10 vs. 14 cmH2O, p = 0.048) and VT/IBW (3.0 vs. 4.0 mL/kg, p = 0.028) were lower in ICU non-survivors, when compared to the survivors. The observed decrease in MP after ECMO initiation did not influence ICU outcome. Waiting for large studies assessing the role of these parameters in VV ECMO patients, RR and MP monitoring should not be underrated during ECMO.

Highlights

The complex interaction between mechanical ventilation (MV) and the native lung may promote ventilator-induced lung injury (VILI), especially in patients suffering from the acute respiratory distress syndrome (ARDS) [1], which would lead to gas exchange impairment and decreased respiratory system compliance [2]
As for all ARDS patients, ∆P has been shown to be an important MV variable correlating with mortality in venous extra-corporeal membrane oxygenation (VV extracorporeal membrane oxygenation (ECMO)) [34,35,36]; there are no large studies showing the effects of ∆P-individualized MV therapy in ECMO patients and lung recovery or patients’ survival [37]
Ranges before ECMO initiation [3], with levels of positive end-expiratory pressure (PEEP) indicating the maintenance of an “open lung” strategy [40,41], even during ECMO. These findings suggest the importance of Mechanical power (MP) monitoring at the bedside, as lung stress may occur even within acceptable ranges of VT, Pplat, and PEEP and might prompt an earlier use of extra-corporeal therapies to reduce the occurrence of VILI

Summary

Introduction

The complex interaction between mechanical ventilation (MV) and the native lung may promote ventilator-induced lung injury (VILI), especially in patients suffering from the acute respiratory distress syndrome (ARDS) [1], which would lead to gas exchange impairment and decreased respiratory system compliance [2]. The concept of lung protective ventilation has been developed and proven to reduce mortality in ARDS patients [3]. Extracorporeal membrane oxygenation (ECMO) has become an effective and safe intervention in severe ARDS, with an increasing use in clinical practice [7,8]. Rely on expert opinions [10]; it is generally accepted that reduced VILI would enhance lung recovery in these patients [11,12]. To perform lung protective ventilation, it is necessary to understand how to reduce the forces applied by MV on lung tissue [13]. An available parameter which accounts for most of the potential causes of VILI has been recently introduced [14,15]: the so-called “mechanical power”

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