Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort.

Rationale: Current practices regarding mechanical ventilation in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown.Objectives: To report current practices regarding mechanical ventilation in patients treated with ECMO for severe acute respiratory distress syndrome (ARDS) and their association with 6-month outcomes.Methods: This was an international, multicenter, prospective cohort study of patients undergoing ECMO for ARDS during a 1-year period in 23 international ICUs.Measurements and Main Results: We collected demographics, daily pre- and per-ECMO mechanical ventilation settings and use of adjunctive therapies, ICU, and 6-month outcome data for 350 patients (mean ± SD pre-ECMO PaO2/FiO2 71 ± 34 mm Hg). Pre-ECMO use of prone positioning and neuromuscular blockers were 26% and 62%, respectively. Vt (6.4 ± 2.0 vs. 3.7 ± 2.0 ml/kg), plateau pressure (32 ± 7 vs. 24 ± 7 cm H2O), driving pressure (20 ± 7 vs. 14 ± 4 cm H2O), respiratory rate (26 ± 8 vs. 14 ± 6 breaths/min), and mechanical power (26.1 ± 12.7 vs. 6.6 ± 4.8 J/min) were markedly reduced after ECMO initiation. Six-month survival was 61%. No association was found between ventilator settings during the first 2 days of ECMO and survival in multivariable analysis. A time-varying Cox model retained older age, higher fluid balance, higher lactate, and more need for renal-replacement therapy along the ECMO course as being independently associated with 6-month mortality. A higher Vt and lower driving pressure (likely markers of static compliance improvement) across the ECMO course were also associated with better outcomes.Conclusions: Ultraprotective lung ventilation on ECMO was largely adopted across medium- to high-case volume ECMO centers. In contrast with previous observations, mechanical ventilation settings during ECMO did not impact patients' prognosis in this context.

An External Validation of Scoring Systems in Mortality Prediction in Veno-Venous Extracorporeal Membrane Oxygenation.

Veno-venous extracorporeal membrane oxygenation (VV ECMO) offers the last resort in the treatment of acute respiratory distress syndrome (ARDS). Various scoring systems have been established, yet external validation of these scoring systems in the Asian population remains scarce. We aim to identify factors associated with hospital mortality and to validate various scoring systems in the prediction of hospital mortality. A retrospective analysis of adults admitted to Pamela Youde Nethersole Eastern Hospital intensive care unit who received VV ECMO from January 1, 2010 to June 30, 2019 was performed. Demographics, ventilation strategies, rescue therapies, and clinical outcomes were compared. The primary outcome was hospital mortality and secondary outcomes were intensive care unit (ICU) mortality, ICU, and hospital length of stay. There were 122 VV ECMO performed for ARDS, of which 78 survived and 44 died. VV ECMO performed for viral pneumonitis was significantly associated with better survival (55.1% vs. 25%, p = 0.001) compared with other causes. As for prediction scores, the PREdiction of Survival on ECMO Therapy-Score had the highest area under receiver operator curve of 0.733 (95% confidence interval [CI]: 0.643-0.823), whereas that of PRedicting dEath for SEvere ARDS on VV ECMO score was 0.662 (95% CI: 0.561-0.764), Respiratory Extracorporeal Membrane Oxygenation Survival Prediction score was 0.657 (95% CI: 0.553-0.761), Sequential Organ Failure Assessment score was 0.652 (95% CI: 0.547-0.757), and VV ECMO mortality score was 0.637 (95% CI: 0.532-0.742). In our cohort, VV ECMO performed for viral pneumonitis was associated with a higher hospital survival. Prediction scores are helpful in our population and provide a useful reference to hospital mortality.