Ultraprotective ventilation allowed by extracorporeal CO2 removal improves the right ventricular function in acute respiratory distress syndrome patients: a quasi-experimental pilot study

Suzanne Goursaud,Damien Du Cheyron,Xavier Valette,Julien Dupeyrat,Cédric Daubin

doi:10.1186/s13613-020-00784-3

Abstract

BackgroundRight ventricular (RV) failure is a common complication in moderate-to-severe acute respiratory distress syndrome (ARDS). RV failure is exacerbated by hypercapnic acidosis and overdistension induced by mechanical ventilation. Veno-venous extracorporeal CO2 removal (ECCO2R) might allow ultraprotective ventilation with lower tidal volume (VT) and plateau pressure (Pplat). This study investigated whether ECCO2R therapy could affect RV function.MethodsThis was a quasi-experimental prospective observational pilot study performed in a French medical ICU. Patients with moderate-to-severe ARDS with PaO2/FiO2 ratio between 80 and 150 mmHg were enrolled. An ultraprotective ventilation strategy was used with VT at 4 mL/kg of predicted body weight during the 24 h following the start of a low-flow ECCO2R device. RV function was assessed by transthoracic echocardiography (TTE) during the study protocol.ResultsThe efficacy of ECCO2R facilitated an ultraprotective strategy in all 18 patients included. We observed a significant improvement in RV systolic function parameters. Tricuspid annular plane systolic excursion (TAPSE) increased significantly under ultraprotective ventilation compared to baseline (from 22.8 to 25.4 mm; p < 0.05). Systolic excursion velocity (S’ wave) also increased after the 1-day protocol (from 13.8 m/s to 15.1 m/s; p < 0.05). A significant improvement in the aortic velocity time integral (VTIAo) under ultraprotective ventilation settings was observed (p = 0.05). There were no significant differences in the values of systolic pulmonary arterial pressure (sPAP) and RV preload.ConclusionLow-flow ECCO2R facilitates an ultraprotective ventilation strategy thatwould improve RV function in moderate-to-severe ARDS patients. Improvement in RV contractility appears to be mainly due to a decrease in intrathoracic pressure allowed by ultraprotective ventilation, rather than a reduction of PaCO2.

Highlights

Right ventricular (RV) failure is a common complication in moderate-to-severe acute respiratory distress syndrome (ARDS)
Pulmonary hypertension may be associated with right ventricular (RV) dysfunction and/or acute cor pulmonale in 20 to 50% of patients with ARDS ventilated with a protective strategy [11]
Eighteen patients with moderate-to-severe ARDS were included in the study

Summary

Introduction

Right ventricular (RV) failure is a common complication in moderate-to-severe acute respiratory distress syndrome (ARDS). The current guidelines recommend a protective ventilation strategy [1] and adjuvant therapeutics such as prone positioning and neuromuscular blockade [2, 3], acute respiratory distress syndrome (ARDS) remains associated with significant mortality [4,5,6]. Pulmonary hypertension may be associated with right ventricular (RV) dysfunction and/or acute cor pulmonale in 20 to 50% of patients with ARDS ventilated with a protective strategy [11]. Right ventricular failure has a deleterious impact on ARDS prognosis [12, 13], and experts recommend a systematic echocardiography assessment to evaluate RV function in patients with ARDS [14]

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