Mechanical Ventilation for Acute Respiratory Distress Syndrome during Extracorporeal Life Support. Research and Practice

• Published in: American journal of respiratory and critical care medicine 2020-03, Vol.201 (5), p.514-525
• Main Authors: Abrams, Darryl, Schmidt, Matthieu, Pham, Tài, Beitler, Jeremy R, Fan, Eddy, Goligher, Ewan C, McNamee, James J, Patroniti, Nicolò, Wilcox, M Elizabeth, Combes, Alain, Ferguson, Niall D, McAuley, Danny F, Pesenti, Antonio, Quintel, Michael, Fraser, John, Hodgson, Carol L, Hough, Catherine L, Mercat, Alain, Mueller, Thomas, Pellegrino, Vin, Ranieri, V Marco, Rowan, Kathy, Shekar, Kiran, Brochard, Laurent, Brodie, Daniel
• Format: Article
• Language: English
• Subjects: Acidosis; Carbon Dioxide; Clinical trials; Extracorporeal Circulation - methods; Extracorporeal Membrane Oxygenation - methods; Humans; Hypoxemia; Life Sciences; Life support systems; Medical research; Oxygen; Pulmonary Gas Exchange; Respiration, Artificial - methods; Respiratory distress syndrome; Respiratory Distress Syndrome - therapy; Ventilator-Induced Lung Injury - prevention & control; Ventilators
• ISSN: 1073-449X; 1535-4970
• DOI: 10.1164/rccm.201907-1283CI

Ventilator-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 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.