TY - JOUR
T1 - Invasive mechanical ventilation in patients with acute respiratory distress syndrome receiving extracorporeal support
T2 - a narrative review of strategies to mitigate lung injury
AU - Zochios, V.
AU - Brodie, D.
AU - Shekar, K.
AU - Schultz, M. J.
AU - Parhar, K. K. S.
N1 - Funding Information: The authors thank Dr J. Kirk-Bayley (Royal Surrey County NHS Foundation Trust, Guildford, Surrey, UK) for his assistance in designing Figure 1. DB receives research support from ALung Technologies. He has been on the medical advisory boards for Abiomed, Xenios, Medtronic, Inspira and Cellenkos. He is the President-elect of the Extracorporeal Life Support Organisation and the Chair of the Executive Committee of the International ECMO Network. MS has been on the advisory boards of Hamilton Medical AG, NovaLung, Xenios and Exvastat. He is currently the global team leader Medical Affairs at Hamilton Medical AG, Bonaduz, Switzerland. The authors did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. No other competing interests declared. Publisher Copyright: © 2022 Association of Anaesthetists.
PY - 2022/10
Y1 - 2022/10
N2 - Veno-venous extracorporeal membrane oxygenation is indicated in patients with acute respiratory distress syndrome and severely impaired gas exchange despite evidence-based lung protective ventilation, prone positioning and other parts of the standard algorithm for treating such patients. Extracorporeal support can facilitate ultra-lung-protective ventilation, meaning even lower volumes and pressures than standard lung-protective ventilation, by directly removing carbon dioxide in patients needing injurious ventilator settings to maintain sufficient gas exchange. Injurious ventilation results in ventilator-induced lung injury, which is one of the main determinants of mortality in acute respiratory distress syndrome. Marked reductions in the intensity of ventilation to the lowest tolerable levels under extracorporeal support may be achieved and could thereby potentially mitigate ventilator-induced lung injury and theoretically patient self-inflicted lung injury in spontaneously breathing patients with high respiratory drive. However, the benefits of this strategy may be counterbalanced by the use of continuous deep sedation and even neuromuscular blocking drugs, which may impair physical rehabilitation and impact long-term outcomes. There are currently a lack of large-scale prospective data to inform optimal invasive ventilation practices and how to best apply a holistic approach to patients receiving veno-venous extracorporeal membrane oxygenation, while minimising ventilator-induced and patient self-inflicted lung injury. We aimed to review the literature relating to invasive ventilation strategies in patients with acute respiratory distress syndrome receiving extracorporeal support and discuss personalised ventilation approaches and the potential role of adjunctive therapies in facilitating lung protection.
AB - Veno-venous extracorporeal membrane oxygenation is indicated in patients with acute respiratory distress syndrome and severely impaired gas exchange despite evidence-based lung protective ventilation, prone positioning and other parts of the standard algorithm for treating such patients. Extracorporeal support can facilitate ultra-lung-protective ventilation, meaning even lower volumes and pressures than standard lung-protective ventilation, by directly removing carbon dioxide in patients needing injurious ventilator settings to maintain sufficient gas exchange. Injurious ventilation results in ventilator-induced lung injury, which is one of the main determinants of mortality in acute respiratory distress syndrome. Marked reductions in the intensity of ventilation to the lowest tolerable levels under extracorporeal support may be achieved and could thereby potentially mitigate ventilator-induced lung injury and theoretically patient self-inflicted lung injury in spontaneously breathing patients with high respiratory drive. However, the benefits of this strategy may be counterbalanced by the use of continuous deep sedation and even neuromuscular blocking drugs, which may impair physical rehabilitation and impact long-term outcomes. There are currently a lack of large-scale prospective data to inform optimal invasive ventilation practices and how to best apply a holistic approach to patients receiving veno-venous extracorporeal membrane oxygenation, while minimising ventilator-induced and patient self-inflicted lung injury. We aimed to review the literature relating to invasive ventilation strategies in patients with acute respiratory distress syndrome receiving extracorporeal support and discuss personalised ventilation approaches and the potential role of adjunctive therapies in facilitating lung protection.
KW - ARDS
KW - ECMO
KW - extracorporeal membrane oxygenation
KW - ultra-lung-protective ventilation
KW - ventilator-induced lung injury
UR - http://www.scopus.com/inward/record.url?scp=85134539496&partnerID=8YFLogxK
U2 - https://doi.org/10.1111/anae.15806
DO - https://doi.org/10.1111/anae.15806
M3 - Review article
C2 - 35864561
SN - 0003-2409
VL - 77
SP - 1137
EP - 1151
JO - Anaesthesia
JF - Anaesthesia
IS - 10
ER -