title: Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study.
abstract: OBJECTIVE
  To describe mechanical ventilation settings in adult patients treated for an acute respiratory distress syndrome with extracorporeal membrane oxygenation and assess the potential impact of mechanical ventilation settings on ICU mortality.
  
  
  METHODS
  Retrospective observational study.
  
  
  METHODS
  Three international high-volume extracorporeal membrane oxygenation centers.
  
  
  METHODS
  A total of 168 patients treated with extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from January 2007 to January 2013.
  
  
  METHODS
  We analyzed the association between mechanical ventilation settings (i.e. plateau pressure, tidal volume, and positive end-expiratory pressure) on ICU mortality using multivariable logistic regression model and Cox-proportional hazards model.
  
  
  RESULTS
  We obtained detailed demographic, clinical, daily mechanical ventilation settings and ICU outcome data. One hundred sixty-eight patients (41 ± 14 years old; PaO2/FIO2 67 ± 19 mm Hg) fulfilled our inclusion criteria. Median duration of extracorporeal membrane oxygenation and ICU stay were 10 days (6-18 d) and 28 days (16-42 d), respectively. Lower positive end-expiratory pressure levels and significantly lower plateau pressures during extracorporeal membrane oxygenation were used in the French center than in both Australian centers (23.9 ± 1.4 vs 27.6 ± 3.7 and 27.8 ± 3.6; p < 0.0001). Overall ICU mortality was 29%. Lower positive end-expiratory pressure levels (until day 7) and lower delivered tidal volume after 3 days on extracorporeal membrane oxygenation were associated with significantly higher mortality (p < 0.05). In multivariate analysis, higher positive end-expiratory pressure levels during the first 3 days of extracorporeal membrane oxygenation support were associated with lower mortality (odds ratio, 0.75; 95% CI, 0.64-0.88; p = 0.0006). Other independent predictors of ICU mortality included time between ICU admission and extracorporeal membrane oxygenation initiation, plateau pressure greater than 30 cm H2O before extracorporeal membrane oxygenation initiation, and lactate level on day 3 of extracorporeal membrane oxygenation support.
  
  
  CONCLUSIONS
  Protective mechanical ventilation strategies were routinely used in high-volume extracorporeal membrane oxygenation centers. However, higher positive end-expiratory pressure levels during the first 3 days on extracorporeal membrane oxygenation support were independently associated with improved survival. Further prospective trials on the optimal mechanical ventilation strategy during extracorporeal membrane oxygenation support are warranted.
authors.affiliation: 1Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, School of Public Health, Monash University, Melbourne, VIC, Australia. 2Medical-Surgical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France. 3Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia. 4Sydney University Medical School, The University of Sydney, Sydney, NSW, Australia. 5Intensive Care Department, Alfred Hospital, Melbourne, VIC, Australia.
authors.forename: Matthieu
authors.initials: M
authors.lastname: Schmidt
authors.forename: Claire
authors.initials: C
authors.lastname: Stewart
authors.forename: Michael
authors.initials: M
authors.lastname: Bailey
authors.forename: Ania
authors.initials: A
authors.lastname: Nieszkowska
authors.forename: Joshua
authors.initials: J
authors.lastname: Kelly
authors.forename: Lorna
authors.initials: L
authors.lastname: Murphy
authors.forename: David
authors.initials: D
authors.lastname: Pilcher
authors.forename: D James
authors.initials: DJ
authors.lastname: Cooper
authors.forename: Carlos
authors.initials: C
authors.lastname: Scheinkestel
authors.forename: Vincent
authors.initials: V
authors.lastname: Pellegrino
authors.forename: Paul
authors.initials: P
authors.lastname: Forrest
authors.forename: Alain
authors.initials: A
authors.lastname: Combes
authors.forename: Carol
authors.initials: C
authors.lastname: Hodgson
mesh_terms: D018806:APACHE; D000328:Adult; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D063305:Organ Dysfunction Scores; D011175:Positive-Pressure Respiration; D016016:Proportional Hazards Models; D012121:Respiration, Artificial / Q000379:methods*; D012128:Respiratory Distress Syndrome / Q000401:mortality* / Q000628:therapy*; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D013990:Tidal Volume