Optimal positive end-expiratory pressure reduces right ventricular dysfunction in COVID-19 patients on venovenous extracorporeal membrane oxygenation: A retrospective single-center study

https://doi.org/10.1016/j.jcrc.2023.154274Get rights and content

Highlights

  • Right ventricular (RV) dysfunction is a well-known complication of ARDS.

  • We studied the effects of titrating PEEP to an optimal transpulmonary pressure on VV-ECMO patients.

  • Optimal PEEP was associated with reduced incidence of hemodynamically significant RV dysfunction.

  • There was also an association of optimal PEEP with improved survival.

Abstract

While mechanical ventilation practices on venovenous extracorporeal membrane oxygenation (VV ECMO) are variable, most institutions utilize a lung rest strategy utilizing relatively low positive end-expiratory pressure (PEEP). The effect of PEEP titration using esophageal manometry during VV ECMO on pulmonary and cardiac function is unknown. This was a retrospective study of 69 patients initiated on VV ECMO between March 2020 through November 2021. Patients underwent standard PEEP (typically 10 cm H2O) or optimal PEEP (PEEP titrated to an end-expiratory transpulmonary pressure 0–3 cm H2O) throughout the ECMO run. The optimal PEEP strategy had higher levels of applied PEEP (17.9 vs. 10.8 cm H2O on day 2 of ECMO), decreased incidence of hemodynamically significant RV dysfunction (4.55% vs. 44.0%, p = 0.0001), and higher survival to decannulation (72.7% vs. 44.0%, p = 0.022). Survival to discharge did not reach statistical significance (61.4% vs. 44.0%, p = 0.211). In univariate logistic regression analysis, optimal PEEP was associated with less hemodynamically significant RV dysfunction with an odds ratio (OR) of 0.06 (95% confidence interval [CI] = 0.01–0.27, p = 0.0008) and increased survival to decannulation with an OR of 3.39 (95% CI 1.23–9.79), p = 0.02), though other confounding factors may have contributed.

Keywords

ECMO
Mechanical ventilation
Positive end-expiratory pressure
COVID-19
Manometry

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