ECMOVENT: Comparing Two Ultraprotective Ventilation Strategies on VV-ECMO
Abstract: The optimal ventilatory strategy for ARDS patients on VV-ECMO remains debated. This single-center, before-and-after study compared two ultraprotective approaches:
- VT1 strategy: Assist-controlled volume mode, VT 1 ml/kg PBW, RR 5/min, Pplat 20–25 cmH₂O.
- ΔP8 strategy: Pressure-controlled mode, ΔP 8 cmH₂O, PEEP 14 cmH₂O, RR 10/min.
Among 121 patients (2016–2023), the ΔP8 group had lower PaCO₂, higher ΔP and mechanical power, but similar survival and ECMO-weaning rates at 90 days.
Key Insights
- Cohort: 121 severe ARDS patients, 69 with VT1 (pre-2021), 52 with ΔP8 (post-2021).
- Respiratory mechanics: Both strategies reduced VT, RR, ΔP, and plateau pressures after ECMO initiation.
- ΔP8 effects: Lower PaCO₂, higher ΔP and RR, more static elastic mechanical power, less prone positioning, and lower ECMO pump flows.
- Outcomes: Survival 30% (VT1) vs 42% (ΔP8, p=0.19). No significant difference in ECMO-weaning time or day-90 mortality.
- CT sub-study: Both strategies showed massive aeration loss and similar recruitment potential; no clear advantage.
Why This Matters
Ultra-protective strategies remain essential to limit VILI during ECMO. This study suggests ΔP8 improves decarboxylation but does not translate into better survival or ECMO liberation compared with quasi-apneic VT1.
Conclusion
Both VT1 and ΔP8 strategies effectively reduce VILI determinants during ECMO. Physiological differences did not yield improved clinical outcomes, underlining the need for prospective multicenter trials.
Take-Home for Clinicians
- Either VT1 or ΔP8 can be safely applied in VV-ECMO ARDS.
- ΔP8 improves CO₂ clearance but increases driving pressure and mechanical power.
- Survival benefit remains unproven—ventilation should be tailored to patient physiology.
Discussion Question: Should ECMO ventilatory strategies focus on PaCO₂ control or strictly on minimizing mechanical power?
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