Background:

Ultra‑lung‑protective ventilation may be useful during veno‑venous extracorporeal membraneoxygenation (vv‑ECMO) for severe acute respiratory distress syndrome (ARDS) to minimize ventilator‑induced lunginjury and to facilitate lung recovery. The objective was to compare pulmonary and systemic biotrauma evaluatedby numerous biomarkers of inflammation, epithelial, endothelial injuries, and lung repair according to two ventilatorstrategies on vv‑ECMO.

Methods:

This is a prospective randomized controlled study. Patients were randomized to receive during 48 h eitherultra‑lung‑protective ventilation combining very low tidal volume (1–2 mL/kg of predicted body weight), low respira‑tory rate (5–10 cycles per minute), positive expiratory transpulmonary pressure, and 16 h of prone position or lung‑protective‑ventilation which followed the ECMO arm of the EOLIA trial (control group).

Results:

The primary outcome was the alveolar concentrations of interleukin‑1‑beta, interleukin‑6, interleukin‑8,surfactant protein D, and blood concentrations of serum advanced glycation end products and angiopoietin‑2 48 hafter randomization. Enrollment was stopped for futility after the inclusion of 39 patients. Tidal volume, respiratoryrate, minute ventilation, plateau pressure, and mechanical power were significantly lower in the ultra‑lung‑protectivegroup. None of the concentrations of the pre‑specified biomarkers differed between the two groups 48 h after rand‑omization. However, a trend to higher 60‑day mortality was observed in the ultra‑lung‑protective group compared tothe control group (45 vs 17%, p = 0.06).

Conclusions:

Despite a significant reduction in the mechanical power, ultra‑lung‑protective ventilation during 48 hdid not reduce biotrauma in patients with vv‑ECMO‑supported ARDS. The impact of this ventilation strategy on clini‑cal outcomes warrants further investigation.