• Darryl Abrams, Matthieu Schmidt, Tài Pham, Jeremy R Beitler, Eddy Fan, Ewan C Goligher, James J McNamee, Nicolò Patroniti, M Elizabeth Wilcox, Alain Combes, Niall D Ferguson, Danny F McAuley, Antonio Pesenti, Michael Quintel, John Fraser, Carol L Hodgson, Catherine L Hough, Alain Mercat, Thomas Mueller, Vin Pellegrino, V Marco Ranieri, Kathy Rowan, Kiran Shekar, Laurent Brochard, and Daniel Brodie.
• Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, New York.
• Am. J. Respir. Crit. Care Med. 2020 Mar 1; 201 (5): 514-525.

AbstractVentilator-induced lung injury remains a key contributor to the morbidity and mortality of acute respiratory distress syndrome (ARDS). Efforts to minimize this injury are typically limited by the need to preserve adequate gas exchange. In the most severe forms of the syndrome, extracorporeal life support is increasingly being deployed for severe hypoxemia or hypercapnic acidosis refractory to conventional ventilator management strategies. Data from a recent randomized controlled trial, a post hoc analysis of that trial, a meta-analysis, and a large international multicenter observational study suggest that extracorporeal life support, when combined with lower Vt and airway pressures than the current standard of care, may improve outcomes compared with conventional management in patients with the most severe forms of ARDS. These findings raise important questions not only about the optimal ventilation strategies for patients receiving extracorporeal support but also regarding how various mechanisms of lung injury in ARDS may potentially be mitigated by ultra-lung-protective ventilation strategies when gas exchange is sufficiently managed with the extracorporeal circuit. Additional studies are needed to more precisely delineate the best strategies for optimizing invasive mechanical ventilation in this patient population.

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