title: Dynamic driving pressure associated mortality in acute respiratory distress syndrome with extracorporeal membrane oxygenation.
abstract: BACKGROUND
  The survival predictors and optimal mechanical ventilator settings in patients with severe acute respiratory distress syndrome (ARDS) undergoing extracorporeal membrane oxygenation (ECMO) are uncertain. This study was designed to investigate the influences of clinical variables and mechanical ventilation settings on the outcomes for severe ARDS patients receiving ECMO.
  
  
  METHODS
  We reviewed severe ARDS patients who received ECMO due to refractory hypoxemia from May 2006 to October 2015. Serial mechanical ventilator settings before and after ECMO and factors associated with survival were analyzed.
  
  
  RESULTS
  A total of 158 severe ARDS patients received ECMO were finally analyzed. Overall intensive care unit (ICU) mortality was 55.1%. After ECMO initiation, tidal volume, peak inspiratory pressure and dynamic driving pressure were decreased, while positive end-expiratory pressure levels were relative maintained. After ECMO initiation, nonsurvivors had significantly higher dynamic driving pressure until day 7 than survivors. Cox proportional hazards regression model revealed that immunocompromised [hazard ratio 1.957; 95% confidence interval (CI) 1.216-3.147; p = 0.006], Acute Physiology and Chronic Health Evaluation (APACHE) II score (hazard ratio 1.039; 95% CI 1.005-1.073; p = 0.023), ARDS duration before ECMO (hazard ratio 1.002; 95% CI 1.000-1.003; p = 0.029) and mean dynamic driving pressure from day 1 to 3 on ECMO (hazard ratio 1.070; 95% CI 1.026-1.116; p = 0.002) were independently associated with ICU mortality.
  
  
  CONCLUSIONS
  For severe ARDS patients receiving ECMO, immunocompromised status, APACHE II score and the duration of ARDS before ECMO initiation were significantly associated with ICU survival. Higher dynamic driving pressure during first 3 days of ECMO support was also independently associated with increased ICU mortality.
authors.affiliation: Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., Kwei-Shan, Taoyuan, 886, Taiwan. pomd54@cgmh.org.tw.
authors.forename: Li-Chung
authors.initials: LC
authors.lastname: Chiu
authors.affiliation: Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., Kwei-Shan, Taoyuan, 886, Taiwan.|Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.|Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan, Taiwan.
authors.forename: Han-Chung
authors.initials: HC
authors.lastname: Hu
authors.affiliation: Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., Kwei-Shan, Taoyuan, 886, Taiwan.
authors.forename: Chen-Yiu
authors.initials: CY
authors.lastname: Hung
authors.affiliation: Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., Kwei-Shan, Taoyuan, 886, Taiwan.
authors.forename: Chih-Hao
authors.initials: CH
authors.lastname: Chang
authors.affiliation: Division of Cardiovascular Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
authors.forename: Feng-Chun
authors.initials: FC
authors.lastname: Tsai
authors.affiliation: Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., Kwei-Shan, Taoyuan, 886, Taiwan.|Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
authors.forename: Cheng-Ta
authors.initials: CT
authors.lastname: Yang
authors.affiliation: Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., Kwei-Shan, Taoyuan, 886, Taiwan.|Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.|Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan, Taiwan.
authors.forename: Chung-Chi
authors.initials: CC
authors.lastname: Huang
authors.affiliation: Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan.
authors.forename: Huang-Pin
authors.initials: HP
authors.lastname: Wu
authors.affiliation: Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., Kwei-Shan, Taoyuan, 886, Taiwan.|Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.|Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan, Taiwan.
authors.forename: Kuo-Chin
authors.initials: KC
authors.lastname: Kao
keywords: Acute respiratory distress syndrome; Driving pressure; Extracorporeal membrane oxygenation; Mechanical ventilation; Outcome