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Physiological and clinical effects of two ultraprotective ventilation strategies in patients with veno-venous extracorporeal membrane oxygenation: the ECMOVENT study

Year: 2025

Type: article

Abstract: The optimal ventilation strategy in acute respiratory distress syndrome (ARDS) patients with veno-venous extracorporeal membrane oxygenation (VV-ECMO) remains unknown. We aimed to compare the effects of two ultra-protective ventilatory strategies applied to patients with ARDS and VV-ECMO. Our study was an observational, retrospective, single-center study with a before-and-after design. All consecutive patients treated with VV-ECMO for severe ARDS between 2016 and 2023 were included. Before 2021, patients received a quasi-apneic ventilation strategy in assist-controlled volume mode with a tidal volume (V T ) of 1 ml.kg −1 predicted body weight (PBW), a respiratory rate (RR) of 5 min −1 and a PEEP set to keep plateau pressure (P PLAT ) between 20 and 25 cmH 2 O. From 2021 onwards, the protocolized ventilatory strategy consisted in pressure-controlled mode with a PEEP of 14 cmH 2 O, a driving pressure (∆P) of 8 cmH 2 O and a RR of 10 min −1 . We evaluated the impact of strategies on longitudinal respiratory mechanics and on the time to successful ECMO weaning at day-90 after VV-ECMO canulation. 121 patients were enrolled, with 69 receiving the VT1 strategy, and 52 the ∆P8 strategy. Over the first 7 days of ECMO, the ∆P8 strategy was associated with significantly higher ∆P and RR, lower PaCO 2 , and higher static elastic mechanical power, compared with the VT1 strategy. The day-90 survival rate was 30% with the VT1 strategy, and 42% with the ∆P8 strategy ( P = 0.19). Time to successful VV-ECMO weaning was 7 [4–13] days in day-90 survivors, with no significant difference between groups. The adjusted subdistribution hazard ratio associated with the ∆P8 strategy was 0.99 (95% confidence interval: 0.53–1.84), as compared to the VT1 strategy ( P > 0.9). In the context of our center, a ventilatory strategy targeting a PEEP of 14 cmH 2 O, a ∆P of 8 cmH 2 O and a RR of 10 min −1 led to the application of ∆P, RR and static elastic mechanical power and improved decarboxylation, compared to a strategy in volumetric mode with a V T of 1 ml.kg −1 PBW and a RR of 5 min −1 , in patients with ARDS and VV-ECMO. No significant difference on clinical outcomes was observed between both strategies.

Source: Annals of Intensive Care

DOI: 10.1186/s13613-025-01525-0