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Published on: October 24, 2018
Mechanical Ventilation in Children on Venovenous ECMO
Matthew L Friedman1, Ryan P Barbaro2,3, Melania M Bembea4
1Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University, Indianapolis, Indiana. friedmml@iu.edu.
Insights
Mechanical ventilation settings in children on venovenous extracorporeal membrane oxygenation (VV-ECMO) vary. High fraction of inspired oxygen (FIO2) is linked to increased mortality, suggesting it
Area of Science:
- Pediatric critical care medicine
- Respiratory physiology
- Extracorporeal life support
Background:
- Venovenous extracorporeal membrane oxygenation (VV-ECMO) supports patients with severe respiratory failure.
- Optimal mechanical ventilation strategies during VV-ECMO are not well-defined.
- Understanding current practices and their impact is crucial for improving outcomes.
Purpose of the Study:
- To describe mechanical ventilation practices in pediatric patients on VV-ECMO.
- To investigate the association between ventilation strategies and clinical outcomes, particularly survival.
Main Methods:
- Multicenter retrospective cohort study of 10 pediatric centers (2011-2016).
- Included children (14 days to 18 years) on VV-ECMO, excluding specific conditions.
- Analyzed ventilator settings and their correlation with mortality.
Main Results:
- Conventional mechanical ventilation was used in ~75% of patients.
- Significant variation observed in ventilator settings, except PEEP.
- Higher fraction of inspired oxygen (FIO2) on days 1-3 was associated with increased mortality (OR 1.38 per 0.1 increase).
- Mortality was higher with high FIO2 (≥0.5) compared to low FIO2 (<0.5) (46% vs 22%).
Conclusions:
- Ventilator mode and settings show considerable practice variation.
- Fraction of inspired oxygen (FIO2) is the only ventilator setting significantly associated with mortality in pediatric VV-ECMO patients.
- Adjusting FIO2 may be a modifiable factor to reduce mortality in this population.
Background:
Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used when mechanical ventilation can no longer support oxygenation or ventilation, or if the risk of ventilator-induced lung injury is considered excessive. The optimum mechanical ventilation strategy once on ECMO is unknown. We sought to describe the practice of mechanical ventilation in children on VV-ECMO and to determine whether mechanical ventilation practices are associated with clinical outcomes.
Methods:
We conducted a multicenter retrospective cohort study in 10 pediatric academic centers in the United States. Children age 14 d through 18 y on VV-ECMO from 2011 to 2016 were included. Exclusion criteria were preexisting chronic respiratory failure, primary diagnosis of asthma, cyanotic heart disease, or ECMO as a bridge to lung transplant.
Results:
Conventional mechanical ventilation was used in about 75% of children on VV-ECMO; the remaining subjects were managed with a variety of approaches. With the exception of PEEP, there was large variation in ventilator settings. Ventilator mode and pressure settings were not associated with survival. Mean ventilator FIO2 on days 1-3 was higher in nonsurvivors than in survivors (0.5 vs 0.4, P = .009). In univariate analysis, other risk factors for mortality were female gender, higher Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS), diagnosis of cancer or stem cell transplant, and number of days intubated prior to initiation of ECMO (all P < .05). In multivariate analysis, ventilator FIO2 was significantly associated with mortality (odds ratio 1.38 for each 0.1 increase in FIO2 , 95% CI 1.09-1.75). Mortality was higher in subjects on high ventilator FIO2 (≥ 0.5) compared to low ventilator FIO2 (> 0.5) (46% vs 22%, P = .001).
Conclusions:
Ventilator mode and some settings vary in practice. The only ventilator setting associated with mortality was FIO2 , even after adjustment for disease severity. Ventilator FIO2 is a modifiable setting that may contribute to mortality in children on VV-ECMO.
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