Mechanical ventilation during extracorporeal membrane oxygenation support – New trends and continuing challenges

Szuldrzynski K, Kowalewski M, Swol J. Mechanical ventilation during extracorporeal membrane oxygenation support – New trends and continuing challenges. Perfusion. 2024;39(1_suppl):107S-114S. doi:10.1177/02676591241232270

Summary of "Mechanical Ventilation During Extracorporeal Membrane Oxygenation Support – New Trends and Continuing Challenges"

Abstract

Mechanical ventilation plays a critical role in the survival of patients supported with veno-venous extracorporeal membrane oxygenation (V-V ECMO) for severe ARDS. Current approaches emphasize lung-protective ventilation strategies, focusing on minimizing mechanical power by reducing tidal volume and driving pressure, using a low respiratory rate, and applying personalized PEEP settings. Increasing use of ECMO for awake, spontaneously breathing patients is emerging, particularly as a bridge to lung transplantation. Understanding the complex interactions between ECMO and native lung function is crucial for optimizing patient care.

Key Points

1. Lung-Protective Ventilation: Guidelines stress reducing mechanical power by minimizing tidal volume, driving pressure, and respiratory rate. Personalized PEEP settings are essential in managing patients on ECMO.

2. Awake ECMO: Increasingly, ECMO is being used in awake, spontaneously breathing patients, particularly as a bridge to lung transplantation.

3. V-V ECMO Gas Exchange: Effective gas exchange during V-V ECMO relies on adjustments in blood flow, sweep gas rate, and oxygenator efficiency, all while accounting for native lung function and metabolic demands.

4. V-A ECMO Challenges: Gas exchange is more complex in veno-arterial ECMO, requiring careful monitoring of left ventricular distension, pulse pressure, and aortic valve function.

5. Mechanical Power: Mechanical power, a marker for energy dissipated into the lungs, combines multiple ventilation variables. Reducing mechanical power helps mitigate ventilator-induced lung injury (VILI).

6. PEEP Titration: Adjusting PEEP to the patient's lung morphology is critical. Recent research suggests that individualizing PEEP with techniques like electrical impedance tomography (EIT) could improve outcomes.

7. ECMO and Mechanical Ventilation Practices: Surveys show that most ECMO centers practice lung rest strategies, with low tidal volume (<5 mL/kg) and driving pressure (≤10-15 cm H2O) being common.

8. Prone Positioning and ECMO: Proning has shown potential benefits for gas exchange and survival in ECMO patients, though its role remains debated, particularly with the need for individualized PEEP titration.

9. Neuromuscular Blocking Agents (NMBAs): Used in early ARDS management, NMBAs are now recommended with caution, often withdrawn as soon as feasible.

10. V-A ECMO Gas Exchange: Managing gas exchange during V-A ECMO requires balancing the ECMO blood flow, patient native cardiac output, and respiratory support, with attention to avoiding hyperoxemia and hypocarbia.

Conclusion

Lung-protective ventilation strategies are crucial for both respiratory and cardiac support on ECMO. Reducing mechanical power, optimizing PEEP, and considering patient-specific factors improve outcomes. The role of prone positioning and other advanced techniques requires further study, but they hold promise for enhancing patient survival.

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Discussion Questions

1. How can mechanical power reduction during ECMO support reduce the risk of ventilator-induced lung injury (VILI)?

2. What are the key challenges in managing gas exchange for patients on veno-arterial ECMO compared to veno-venous ECMO?

3. How might individualized PEEP settings, aided by new technologies like electrical impedance tomography (EIT), improve patient outcomes during ECMO support?

Javier Amador-Casta?eda, BHS, RRT, FCCM

Interprofessional Critical Care Network (ICCN)