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Don't Drive Blind: Driving Pressure to Optimize Ventilator Management in ECMO
Ena Gupta1,2, Bharat Awsare3, Hitoshi Hirose4
1Division of Pulmonary and Critical Care, Jane and Leonard Korman Respiratory Institute, Jefferson Health and National Jewish Health, Thomas Jefferson University, 834 Walnut Street, Suite 650, Philadelphia, PA, 19107, USA. enagupta8@gmail.com.
Higher driving pressure (DP) after initiating extracorporeal membrane oxygenation (ECMO) is linked to increased mortality. Individualized ventilator strategies are crucial for patients on ECMO to minimize lung injury.
Area of Science:
- Critical Care Medicine
- Pulmonary Medicine
- Mechanical Ventilation
Background:
- Driving pressure (DP) is a known factor in Acute Respiratory Distress Syndrome (ARDS) management.
- Limited research exists on DP in patients on extracorporeal membrane oxygenation (ECMO) without ARDS.
- Understanding DP's role in all ECMO patients is essential for optimizing outcomes.
Purpose of the Study:
- To investigate the association between driving pressure (DP) and mortality in all patients undergoing ECMO.
- To compare changes in DP before and after ECMO initiation across different patient groups.
- To identify potential ventilator strategies for improving patient outcomes on ECMO.
Main Methods:
- Retrospective review of consecutive patients on veno-arterial or veno-venous ECMO from August 2010 to February 2017.
- Comparison of DP levels before and after ECMO initiation.
- Multivariable analysis to assess the association of DP with 30-day mortality.
Main Results:
- A significant proportion of patients (46%) showed an increase in DP after ECMO initiation.
- Increased DP was associated with higher initial PEEP and greater PEEP decrease post-ECMO.
- Higher DP 24 hours after ECMO initiation independently predicted increased 30-day mortality (OR 1.15).
Conclusions:
- An increase in driving pressure and a decrease in respiratory compliance are common after ECMO initiation.
- Elevated DP post-ECMO initiation is a significant predictor of increased 30-day mortality.
- Tailored ventilator strategies are necessary to mitigate mechanical stress in ECMO patients.
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