Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome An International Multicenter Prospective Cohort
Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome An International Multicenter Prospective Cohort
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DOI：
10.1164/rccm.201806-1094oc
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发表时间：
2019-10-15
影响因子：
24.7
通讯作者：
Smith, Roger
中科院分区：
文献类型：
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作者：
Schmidt, Matthieu;Tai Pham;Smith, Roger
基本原理：目前关于使用体外膜肺氧合（ECMO）治疗急性呼吸窘迫综合征（ARDS）患者的机械通气的实践尚不清楚。目的：报告使用ECMO治疗严重急性呼吸窘迫综合征（ARDS）患者的机械通气的当前实践及其与6个月结局的相关性。方法：这是一项国际性、多中心、前瞻性队列研究，在23个国际ICU接受ECMO治疗ARDS的患者中进行了为期1年的研究。我们收集了350例患者的人口统计学资料、每日ECMO前和ECMO前后机械通气设置和连续治疗的使用、ICU和6个月结局数据（平均值+/- SD ECMO前Pa-O2/FIO 2 71 +/- 34 mm Hg）。ECMO前俯卧位和神经肌肉阻滞剂的使用率分别为26%和62%。V-T（6.4 +/- 2.0 vs. 3.7 +/- 2.0 ml/kg），平台压（32 +/- 7 vs. 24 +/- 7 cm H2O），驱动压力（20 +/- 7 vs. 14 +/- 4 cm H2O），呼吸频率（26 +/- 8 vs. 14 = 6次呼吸/min）和机械功率（26.1 +/- 12.7 vs. 6.6 +/- 4.8 J/min）在ECMO启动后显著降低。6个月生存率为61%。在多变量分析中未发现ECMO前2天的呼吸机设置与生存率之间存在关联。一个随时间变化的考克斯模型保留了年龄较大、液体平衡较高、乳酸水平较高以及在沿着ECMO过程中需要更多肾脏替代治疗与6个月死亡率独立相关。较高的VT和较低的驱动压力（静态顺应性改善的可能标志）在整个ECMO课程也与更好的outcomes.Conclusions：超保护性肺通气ECMO主要是通过在中等到高的情况下，体积ECMO中心。与以前的观察结果相反，ECMO期间的机械通气设置在这种情况下不会影响患者的预后。
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 Pa-O2/FIO2 71 +/- 34 mm Hg). Pre-ECMO use of prone positioning and neuromuscular blockers were 26% and 62%, respectively. V-T (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.