• Matthieu Schmidt, Tài Pham, Antonio Arcadipane, Cara Agerstrand, Shinichiro Ohshimo, Vincent Pellegrino, Alain Vuylsteke, Christophe Guervilly, Shay McGuinness, Sophie Pierard, Jeff Breeding, Claire Stewart, Simon Sin Wai Ching, Janice M Camuso, R Scott Stephens, Bobby King, Daniel Herr, Marcus J Schultz, Mathilde Neuville, Elie Zogheib, Jean-Paul Mira, Hadrien Rozé, Marc Pierrot, Anthony Tobin, Carol Hodgson, Sylvie Chevret, Daniel Brodie, and Alain Combes.
• INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, UPMC Univ Paris 06, Sorbonne Université, Paris, France.
• Am. J. Respir. Crit. Care Med. 2019 Oct 15; 200 (8): 1002-1012.

AbstractRationale: 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.

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