Mechanical ventilation in patients subjected to extracorporeal membrane oxygenation (ECMO)

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López Sanchez" "autores" => array:1 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "López Sanchez" "email" => array:1 [ 0 => "martalopez@humv.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ventilación mecánica en pacientes tratados con membrana de oxigenación extracorpórea (ECMO)" ] ] "textoCompleto" => "IntroductionMechanical ventilation (MV) constitutes the basis of management in patients with acute respiratory distress syndrome (ARDS) and respiratory failure of other origins. To date, only MV with low tidal volume (Vt) and limitation of plateau pressure (Pp) has been found to reduce mortality in these patients.<a class="elsevierStyleCrossRef" href="#bib0195">1</a> In more recent studies, MV in prone decubitus has been observed to improve survival in patients with severe ARDS.<a class="elsevierStyleCrossRef" href="#bib0200">2</a>Despite the technological advances in recent years, mortality due to ARDS remains high (40–50%).<a class="elsevierStyleCrossRef" href="#bib0205">3</a> In the more serious presentations of the syndrome, with PaO2/FiO2≤100mmHg, according to the new definition of Berlin,<a class="elsevierStyleCrossRef" href="#bib0210">4</a> the expectable mortality rate would be 45%, though historically it has been reported that mortality can exceed 60%.<a class="elsevierStyleCrossRef" href="#bib0215">5</a> However, in a recent study involving 98 patients with ARDS, the in-hospital mortality rate was 37.7%, and did not differ between moderate and severe ARDS. In this regard, mortality was seen to depend on other factors such as Pp>30cmH2O during the first 72h.<a class="elsevierStyleCrossRef" href="#bib0220">6</a>Extracorporeal membrane oxygenation (ECMO) allows ventilatory support in the form of venovenous ECMO (VV ECMO) or cardiac and respiratory support through veno-arterial ECMO (VA ECMO). The use of ECMO has increased in recent years, fundamentally due to the good outcomes obtained with the technique (particularly with VV ECMO) in the influenza A (H1N1) epidemic, where survival rates of 77% were reached with ECMO in reference centers,<a class="elsevierStyleCrossRef" href="#bib0225">7</a> and also as a consequence of the technological improvements (use of centrifuge pumps, oxygenation membranes of longer duration), greater biocompatibility of the systems, and lesser anticoagulation needs.<a class="elsevierStyleCrossRef" href="#bib0230">8</a>Extracorporeal membrane oxygenation is a rescue strategy in refractory respiratory failure that affords oxygenation and CO2 clearance. However, it also allows us to apply a protective (Vt 4–8ml/kg ideal b.w., Pp<28–30cmH2O) or “ultraprotective” ventilation strategy (Vt≤4ml/kg ideal b.w., Pp<25cmH2O) in order to minimize ventilator-induced lung injury (VILI).<a class="elsevierStyleCrossRef" href="#bib0235">9</a> Carbon dioxide removal (ECCO2R) is simpler than VV ECMO, and has been shown to lower the concentration of cytokines at pulmonary level (in bronchoalveolar lavage [BAL]) when ventilating with Vt≤6ml/kg ideal b.w., thereby affording effective elimination of CO2.<a class="elsevierStyleCrossRef" href="#bib0240">10</a> These systems effectively clear CO2 in patients with hypercapnia of different etiologies, but also allow ultraprotective ventilation in patients with severe ARDS – the benefits of which remain to be determined.<a class="elsevierStyleCrossRef" href="#bib0245">11</a> In the absence of VV ECMO or ECCO2R, we would be obliged to accept permissive hypercapnia and/or hypoxemia levels that are not clearly established. Nevertheless, although this type of ventilation with VV ECMO or ECCO2R appears promising, no beneficial impact in terms of mortality has yet been established,<a class="elsevierStyleCrossRef" href="#bib0250">12</a> and currently most centers place priority on weaning from extracorporeal devices versus weaning from the ventilator.<a class="elsevierStyleCrossRef" href="#bib0255">13</a>There are no clinical evidence-based guidelines recommending a concrete form of ventilation in patients subjected to VV ECMO, though 77% of the centers with experience apply the “lung rest” concept, with low Vt, low respiratory frequency (RF), and high positive end-expiratory pressure (PEEP).<a class="elsevierStyleCrossRef" href="#bib0255">13</a>Ventilator-induced lung injuryVentilator-induced lung injury occurs at four levels. The use of high plateau pressures induces barotrauma; injury derived from ventilation with high Vt causes volutrauma; and the activation of certain inflammatory processes in the alveolar endothelial and epithelial cells induced by aggressive MV gives rise to biotrauma. Furthermore, the cyclic opening and closing of the alveolar units produces atelectrauma—the latter being defined as the percentage of collapsed lung that opens at the end of inspiration and collapses again at the end of expiration.<a class="elsevierStyleCrossRef" href="#bib0260">14</a>The lung with ARDS is heterogeneous. Studies involving thoracic computed tomography (CT) have demonstrated the existence of areas with collapsed alveoli in dependent zones and others with ventilated alveoli in non-dependent zones, which are those that receive most of the Vt. The use of protective ventilation with Vt 6ml/kg produces alveolar overdistension in almost 30% of all cases of ARDS.<a class="elsevierStyleCrossRef" href="#bib0195">1</a> Patients with ARDS and treated with ECMO are intensely hypoxemic, with large zones of collapsed lung, often affecting all four lung quadrants. As a result, the ventilated alveoli receive most of the Vt and are subject to overdistension despite the adoption of protective ventilation measures.<a class="elsevierStyleCrossRef" href="#bib0265">15</a> However, it does not seem that Vt exclusively plays an important role in the development of VILI, though we need regional and dynamic data on pulmonary ventilation and circulation in patients with ARDS in order to evaluate the application of different ventilation strategies. In this regard, and in addition to thoracic CT, electrical impedance tomography (EIT) affords real-time visioning of regional ventilation and produces information about how the different ventilatory parameters affect the lung, with a view to minimizing VILI.<a class="elsevierStyleCrossRef" href="#bib0270">16</a>The degree to which cyclic alveolar opening and closing, and alveolar overdistension, contribute to VILI is not clear. A study involving patients with acute lung injury (ALI) and ARDS treated with high PEEP measured alveolar inflammatory activity using positron-emission tomography (PET) and alveolar distension with CT at the end of inspiration and at the end of expiration. Inflammation in the ventilated lung regions and in the rest of the lung was related to Pp>26–27cmH2O, though no association was found between metabolic activity and cyclic alveolar opening and closing.<a class="elsevierStyleCrossRef" href="#bib0275">17</a>The use of high PEEP to improve alveolar recruitment, minimizing alveolar overdistension, has not been shown to reduce mortality in patients with ARDS.<a class="elsevierStyleCrossRef" href="#bib0280">18</a> In patients treated with ECMO, the use of high PEEP (>10cmH2O) in the first three days of extracorporeal support was independently correlated to a decrease in mortality.<a class="elsevierStyleCrossRef" href="#bib0285">19</a>Therefore, a protective ventilation strategy should always be adopted in patients with ARDS with or without ECMO, though we do not know how to use PEEP for reducing VILI in these individuals, where the existence of pulmonary heterogeneity is a fact. The increase in PEEP protects the lungs, provided it is accompanied by a change in lung mechanics, i.e., the same Vt should result in improved respiratory compliance (CRS).<a class="elsevierStyleCrossRef" href="#bib0290">20</a> In this regard, studies involving high PEEP have not demonstrated benefits in terms of survival,<a class="elsevierStyleCrossRef" href="#bib0295">21</a> though PEEP has been shown to offer benefit in patients with increased lung recruitability.<a class="elsevierStyleCrossRef" href="#bib0300">22</a>A decrease in driving pressure (ΔP=Vt/CRS) is the factor that has been associated to improved survival in ARDS patients, considering that CRS is closely related to the aerated lung volume, i.e., functional lung size.<a class="elsevierStyleCrossRef" href="#bib0290">20</a> Calculated as Pp-PEEP (cmH2O), a decrease in ΔP is associated to an improved prognosis, while an increase is associated to a poorer prognosis.Mode of mechanical ventilation with extracorporeal membrane oxygenationThe MV mode to be used in patients subjected to ECMO has not been established, and no comparative studies are available. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the different ventilation modes in patients subjected to VV ECMO, according to the opinion of different expert sources.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In a recent international study involving 141 centers from 28 countries on all continents and belonging to the Extracorporeal Life Support Organization (ELSO), most of the centers (62%) were seen to use controlled MV modes, while only 27% used assist modes in patients with VV ECMO.<a class="elsevierStyleCrossRef" href="#bib0255">13</a> In the international study recently published by Camporota et al., involving 133 surveyed centers, the pressure control mode was used in 64.4% of the centers, the pressure assist mode in 47.3%, bilevel positive airway pressure (BiPAP) in 17.1%, volume control mode in 11.6%, airway pressure release ventilation (APRV) in 4.6%, and neurally adjusted ventilatory assist (NAVA) and high-frequency ventilation in 1% of the centers.<a class="elsevierStyleCrossRef" href="#bib0305">23</a> Lastly, in a multicenter study in three hospitals in Australia and France, 55% of the patients subjected to ECMO (VV ECMO the 98% of the cases) received pressure control modes.<a class="elsevierStyleCrossRef" href="#bib0285">19</a>In general, pressure modes allow daily monitoring of Vt, providing information on the improvement or worsening of lung compliance, and make it possible to increase Vt to at least 6ml/kg for starting weaning from VV ECMO. The inconvenience is that the limitation of Vt may prove difficult in assist mode.<a class="elsevierStyleCrossRef" href="#bib0310">24</a> The APRV mode requires spontaneous ventilation of the patient, and may be an alternative to the pressure control mode in patients with spontaneous ventilation.<a class="elsevierStyleCrossRef" href="#bib0265">15</a>In the early stages of ARDS it is more difficult to maintain spontaneous ventilation, and the patient is often under neuromuscular block. After this phase, spontaneous ventilation allows respiratory muscle and diaphragmatic training, with a decrease in the sedation requirements, though when poorly applied it can worsen patient-ventilator asynchrony.<a class="elsevierStyleCrossRef" href="#bib0310">24</a> The NAVA mode in patients subjected to ECMO reduces patient-ventilator asynchrony in the lung function recovery phase.<a class="elsevierStyleCrossRef" href="#bib0315">25</a>Tidal volume and plateau pressure with extracorporeal membrane oxygenationOf the centers belonging to the ELSO, and with regard to the Vt used, 76% claimed to ventilate their patients with Vt≤6ml/kg, while 21% specified no Vt value during support with VV ECMO.<a class="elsevierStyleCrossRef" href="#bib0255">13</a> In animals, a reduction of Vt<4ml/kg ideal b.w. has been associated to a decrease in lung edema and injury.<a class="elsevierStyleCrossRef" href="#bib0320">26</a> In the Xtravent multicenter study, “ultraprotective ventilation” with ECCO2R versus protective ventilation did not result in a decrease in the days of MV, though a reduction of alveolar interleuking-6 levels was observed,<a class="elsevierStyleCrossRef" href="#bib0250">12</a> as previously reported.<a class="elsevierStyleCrossRef" href="#bib0240">10</a> In the post hoc analysis, in the group of patients with PaO2/FiO2≤150mmHg, a decrease was recorded in the days of MV in the group subjected to ECCO2R (40.9±12.8 vs 28.2±16.4; p=0.033).<a class="elsevierStyleCrossRef" href="#bib0250">12</a>According to a recent systematic review involving 2042 patients in 49 studies, the tendency is to use an “ultraprotective” strategy, ventilating with Vt≤4ml/kg in order to limit Pp to ≤30cmH2O. This practice possibly reflects the impossibility of maintaining adequate ventilation without a risk of lung injury before starting extracorporeal support.<a class="elsevierStyleCrossRef" href="#bib0320">26</a> In another international survey, 31% of the centers were seen to ventilate patients with ECMO using an “ultraprotective” strategy.<a class="elsevierStyleCrossRef" href="#bib0255">13</a> According to different studies, the way in which we use MV during support with VV ECMO appears to have an impact upon mortality.<a class="elsevierStyleCrossRefs" href="#bib0265">15,26,27</a> The study published by Pham et al. shows the reduction of Pp on the first day of ECMO to be independently associated to lowered mortality.<a class="elsevierStyleCrossRef" href="#bib0330">28</a> Likewise, in an international multicenter study, one of the predictors of mortality in patients treated with ECMO was Pp>30cmH2O before introducing ECMO.<a class="elsevierStyleCrossRef" href="#bib0285">19</a>The Predicting death for severe ARDS on VV-ECMO (PRESERVE) mortality risk score takes 8 pre-ECMO parameters into account in predicting the probability of survival in patients with severe ARDS treated with VV ECMO. Patient age, body mass index, immunosuppression, the use of prone decubitus, the days of MV, the SOFA score, PEEP and Pp>30cmH2O were the calculated parameters.<a class="elsevierStyleCrossRef" href="#bib0335">29</a>There are no recommendations on how to proceed in lowering Vt once VV ECMO support has been started. A reduction in the first 1–3 days of support to <4ml/kg ideal b.w. could be proposed.<a class="elsevierStyleCrossRef" href="#bib0285">19</a> In a recent study, only the parameter Pp≤31cmH2O was associated to in-hospital survival.<a class="elsevierStyleCrossRef" href="#bib0340">30</a>Positive end-expiratory pressure with extracorporeal membrane oxygenationIn patients with ARDS, PEEP is used to maintain alveolar recruitment, improve oxygenation and prevent VALI (atelectrauma with cyclic alveolar opening and closing). However, alveolar overdistension and the increase in right ventricular afterload are deleterious effects of the indiscriminate use of PEEP.The PEEP level to be used in patients treated with ECMO is subject to controversy. The reduction of Vt, particularly when “ultraprotective ventilation” is used (Vt<4ml/kg ideal b.w.), can produce atelectasis with worsening of the ventilation/perfusion ratio. The ELSO therefore recommends a PEEP level of 10cmH2O, in contrast to the protocol established by Richard et al. in the Consensus Conference, where the recommendation is simply to use “minimum PEEP” for “minimum Pp” (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Higher PEEP levels could cause alveolar overdistension,<a class="elsevierStyleCrossRef" href="#bib0280">18</a> as well as reduce venous return in patients with VV ECMO and worsen right ventricular function in VA ECMO.<a class="elsevierStyleCrossRef" href="#bib0265">15</a>In patients with VV ECMO, PEEP is not necessary to improve oxygenation, except in intensely hypoxemic individuals or cases requiring high blood flows (>5l/min) during support (e.g., septic shock patients). In contrast to VV ECMO, the ECCO2R systems require PEEP and FiO2 in the respirator in order to improve oxygenation, since they operate with a much lower blood flow than VV ECMO, and CO2 clearance is fundamentally dependent upon the flow of gas.<a class="elsevierStyleCrossRefs" href="#bib0245">11,31,32</a>In ECMO, the use of high PEEP levels would favor alveolar recruitment, which in turn could accelerate lung recovery through the prevention of capillary loss and macrophage activation generated in lung hypoxemic regions induced by the presence of atelectasis.<a class="elsevierStyleCrossRefs" href="#bib0240">10,28,33</a>In an international survey involving 133 centers, 63% used a fixed PEEP level, 21% introduced adjustments according to compliance, 9.3% did so according to the radiological findings, and 7.3% introduced adjustments according to EIT. In turn, 34.9% of the centers used PEEP≥10cmH2O, while 27.9% used PEEP levels below this value. Only 15.5% used PEEP 15–20cmH2O.<a class="elsevierStyleCrossRef" href="#bib0355">33</a>As has been commented above, in a retrospective study, the use of PEEP<10cmH2O during the first three days of treatment with ECMO was associated to increased mortality. On the other hand, in a more recent retrospective study involving 62 patients, a one-point PEEP increment was seen to be associated to a 36.2% decrease in the odds ratio for survival 30 days after discharge (95%CI 10.8–54.4%; p=0.009)(PEEP survivors 8.5±2, survivors 7.3±2; p=0.04).<a class="elsevierStyleCrossRef" href="#bib0340">30</a> In patients exposed to increased overdistension, the effect of PEEP may prove deleterious, and in patients with more recruitable areas we could perhaps use higher PEEP levels.<a class="elsevierStyleCrossRef" href="#bib0360">34</a>It therefore would be very difficult to recommend a PEEP level in these patients. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the different recommendations of groups of experts. The latest ELSO guides warn that “in patients with respiratory failure and ECMO, it could be a mistake to try to recruit lung volume in the early stages”. This would speak in favor of the risk of pulmonary overdistension in certain patients, recommending PEEP levels of between 5 and 15cmH2O.<a class="elsevierStyleCrossRef" href="#bib0365">35</a> In the same sense, according to the only European Consensus Conference on ECMO of 2014, the recommendation for ventilating ARDS patients with ECMO would be to “adjust MV to minimize Pp while we apply minimum PEEP”.<a class="elsevierStyleCrossRef" href="#bib0370">36</a> In patients with ARDS due to influenza A (H1N1), the Réseau Europeen de Recherche en Ventilation Artificielle (REVA) recommended lowering Vt to maintain Pp≤20–25cmH2O, with the application of PEEP≥10cmH2O.<a class="elsevierStyleCrossRef" href="#bib0375">37</a>As has been commented above, driving pressure (ΔP=Pp−PEEP) is the factor that has been associated to improved survival in ARDS patients.<a class="elsevierStyleCrossRef" href="#bib0290">20</a> In patients with ECMO, previous studies have shown high ΔP to be associated to poorer survival.<a class="elsevierStyleCrossRefs" href="#bib0245">11,19</a> In a recent study carried out to assess the association among the different ventilatory parameters during ECMO indicated for refractory hypoxemia in ARDS, the authors concluded that increased ΔP is the only ventilatory parameter during ECMO showing an independent association to in-hospital mortality in these patients.<a class="elsevierStyleCrossRef" href="#bib0380">38</a> In this study, Serpa-Neto et al. included 545 patients from 9 studies, where in addition to ΔP, advanced age, the male sex and a low body mass index were also seen to be independently associated to mortality.Respiratory frequencyThe RF to be used in patients subjected to ECMO has likewise not been established. The ELSO recommended a low RF (4–5rpm) to avoid mechanical lung “stress”, though in general the range is between 4 and 30rpm as evidenced by the literature.<a class="elsevierStyleCrossRef" href="#bib0265">15</a> In general, the adjustment of RF aims to ensure maintenance of the arterial pH, but this concept changes in patients subjected to VV ECMO, where maintenance of the arterial pH and PaCO2 are directly dependent upon the flow of gas in the oxygenation membrane. In this context, PaCO2 is to be slowly reduced once support has been started, with a gas/blood flow of 1:1 in ECMO.<a class="elsevierStyleCrossRefs" href="#bib0345">31,32</a>In a recent international survey, 55% of the centers ventilated their patients subjected to ECMO with a RF of 5–10rpm,<a class="elsevierStyleCrossRef" href="#bib0305">23</a> possibly reflecting a tendency to ventilate with lower RF as in the “lung rest” model proposed by Gattinoni et al. years ago, and in which ventilation with a low RF (3–5rpm) and a low peak inspiratory pressure with an ECCO2R system in patients suffering severe ARDS of pulmonary origin resulted in improved lung function in 72.8% of the patients.<a class="elsevierStyleCrossRef" href="#bib0360">34</a> In this regard, the latest recommendations of the ELSO are to “use MV with low parameters in order to allow lung rest”.<a class="elsevierStyleCrossRef" href="#bib0365">35</a>Fraction of inspired O2 in patients with extracorporeal membrane oxygenationIt is clear that in order to minimize VILI we must lower FiO2 to minimum levels, with the purpose of maintaining SatpO2>80% in VV ECMO,<a class="elsevierStyleCrossRef" href="#bib0345">31</a> or between 84 and 88% according to the different groups.<a class="elsevierStyleCrossRefs" href="#bib0365">35,37</a>ConclusionsIn patients with ARDS, MV with the reduction of Pp has been shown to reduce mortality. However, there are no clear evidences, guides or recommendations on how to ventilate patients subjected to ECMO. A decrease in driving pressure has been associated to improved in-hospital survival among patients with severe ARDS treated with ECMO. The monitoring of this MV parameter therefore could be recommended in the same way as in patients without ECMO.Since extracorporeal systems oxygenate and clear CO2, protective and “ultraprotective” MV is possible, and would allow a reduction of VILI in these patients. The lowering of Vt (<4ml/kg ideal b.w.), Pp (<25cmH2O), PEEP (5–15cmH2O) and RF allows us to maintain lung rest, avoiding alveolar overdistension, biotrauma and atelectrauma. Further studies are needed to demonstrate the impact of this ventilatory strategy upon the mortality of patients with severe ARDS treated with VV ECMO or ECCO2R systems.Conflicts of interestThere are no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres933248" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec907603" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres933249" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec907602" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Ventilator-induced lung injury" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Mode of mechanical ventilation with extracorporeal membrane oxygenation" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Tidal volume and plateau pressure with extracorporeal membrane oxygenation" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Positive end-expiratory pressure with extracorporeal membrane oxygenation" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Respiratory frequency" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Fraction of inspired O in patients with extracorporeal membrane oxygenation" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 13 => array:2 [ "identificador" => "xack315030" "titulo" => "Acknowledgements" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-11-07" "fechaAceptado" => "2016-12-14" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec907603" "palabras" => array:10 [ 0 => "Mechanical ventilation" 1 => "Acute respiratory distress syndrome" 2 => "Extracorporeal membrane oxygenation" 3 => "Venovenous extracorporeal membrane oxygenation" 4 => "Lung rest" 5 => "Protective ventilation" 6 => "Ultraprotective ventilation" 7 => "Ventilator induced lung injury" 8 => "Extracorporeal CO2 removal" 9 => "Driving pressure" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec907602" "palabras" => array:10 [ 0 => "Ventilación mecánica" 1 => "Síndrome de distrés respiratorio agudo" 2 => "Membrana de oxigenación extracorpórea" 3 => "Membrana de oxigenación extracorpórea venovenosa" 4 => "Lung rest" 5 => "Ventilación protectora" 6 => "Ventilación ultraprotectora" 7 => "Lesión pulmonar asociada a ventilación mecánica" 8 => "Sistemas depuradores de carbónico" 9 => "Driving pressure" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Mechanical ventilation (MV) is a crucial element in the management of acute respiratory distress syndrome (ARDS), because there is high level evidence that a low tidal volume of 6ml/kg (protective ventilation) improves survival. In these patients with refractory respiratory insufficiency, venovenous extracorporeal membrane oxygenation (ECMO) can be used. This salvage technique improves oxygenation, promotes CO2 clearance, and facilitates protective and ultraprotective MV, potentially minimizing ventilation-induced lung injury.Although numerous trials have investigated different ventilation strategies in patients with ARDS, consensus is lacking on the optimal MV settings during venovenous ECMO. Although the concept of “lung rest” was introduced years ago, there are no evidence-based guidelines on its use in application to MV in patients supported by ECMO. How MV in ECMO patients can promote lung recovery and weaning from ventilation is not clear.The purpose of this review is to describe the ventilation strategies used during venovenous ECMO in clinical practice." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La ventilación mecánica (VM) es clave en el manejo del síndrome de distrés respiratorio del adulto (SDRA) ya que existe un alto nivel de evidencia de que la ventilación con volúmenes tidales de 6ml/kg (ventilación protectora) mejora la supervivencia. La oxigenación con membrana extracorpórea (ECMO) veno-venosa es una terapia de rescate en el tratamiento de la insuficiencia respiratoria refractaria que mejora la oxigenación, reduce el CO2 y facilita la aplicación de VM protectora, reduciendo potencialmente la lesión pulmonar asociada a VM.Aunque las estrategias ventilatorias en pacientes con SDRA han sido analizadas en numerosos estudios, no existe consenso respecto a cómo ventilar a pacientes con ECMO veno-venosa. El concepto de «lung rest», introducido hace años, carece aún de evidencias para recomendar su uso pero podría promover la recuperación pulmonar y facilitar el destete de la VM.El objetivo de esta revisión es describir las diferentes estrategias de ventilación en pacientes tratados con ECMO veno-venosa." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: López Sanchez M. Ventilación mecánica en pacientes tratados con membrana de oxigenación extracorpórea (ECMO). Med Intensiva. 2017;41:491–496." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "PEEP: positive end-expiratory pressure; Pp: plateau pressure; FiO2: inspired fraction of oxygen; RF: respiratory frequency; REVA: Réseau Europeen de Recherche en Ventilation Artificielle; PCV: pressure control ventilation; VCV: volume control ventilation; MV: mechanical ventilation; Vt: tidal volume." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Source \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MV objective \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MV mode \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Vt \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pp \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PEEP (cmH2O) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RF (rpm) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FiO2 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ELSO guides 2013<a class="elsevierStyleCrossRef" href="#bib0365">35</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">PCV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10–15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">European Network of MV (REVA)<a class="elsevierStyleCrossRef" href="#bib0375">37</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">VCV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≤20–25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6–20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3–0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Consensus Conference ECMO<a class="elsevierStyleCrossRef" href="#bib0370">36</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lung rest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Minimize Pp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Minimum PEEP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1577185.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Mechanical ventilation in VV ECMO according to the opinion of different expert sources." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:38 [ 0 => array:3 [ "identificador" => "bib0195" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress síndrome. 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Mechanical ventilation in patients subjected to extracorporeal membrane oxygenation (ECMO)

Ventilación mecánica en pacientes tratados con membrana de oxigenación extracorpórea (ECMO)

M. López Sanchez

Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Mechanical ventilation &#40;MV&#41; constitutes the basis of management in patients with acute respiratory distress syndrome &#40;ARDS&#41; and respiratory failure of other origins&#46; To date&#44; only MV with low tidal volume &#40;Vt&#41; and limitation of plateau pressure &#40;Pp&#41; has been found to reduce mortality in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> In more recent studies&#44; MV in prone decubitus has been observed to improve survival in patients with severe ARDS&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite the technological advances in recent years&#44; mortality due to ARDS remains high &#40;40&#8211;50&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">3</span></a> In the more serious presentations of the syndrome&#44; with PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mmHg&#44; according to the new definition of Berlin&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a> the expectable mortality rate would be 45&#37;&#44; though historically it has been reported that mortality can exceed 60&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">5</span></a> However&#44; in a recent study involving 98 patients with ARDS&#44; the in-hospital mortality rate was 37&#46;7&#37;&#44; and did not differ between moderate and severe ARDS&#46; In this regard&#44; mortality was seen to depend on other factors such as Pp<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during the first 72<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Extracorporeal membrane oxygenation &#40;ECMO&#41; allows ventilatory support in the form of venovenous ECMO &#40;VV ECMO&#41; or cardiac and respiratory support through veno-arterial ECMO &#40;VA ECMO&#41;&#46; The use of ECMO has increased in recent years&#44; fundamentally due to the good outcomes obtained with the technique &#40;particularly with VV ECMO&#41; in the influenza A &#40;H1N1&#41; epidemic&#44; where survival rates of 77&#37; were reached with ECMO in reference centers&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">7</span></a> and also as a consequence of the technological improvements &#40;use of centrifuge pumps&#44; oxygenation membranes of longer duration&#41;&#44; greater biocompatibility of the systems&#44; and lesser anticoagulation needs&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Extracorporeal membrane oxygenation is a rescue strategy in refractory respiratory failure that affords oxygenation and CO<span class="elsevierStyleInf">2</span> clearance&#46; However&#44; it also allows us to apply a protective &#40;Vt 4&#8211;8<span class="elsevierStyleHsp" style=""></span>ml&#47;kg ideal b&#46;w&#46;&#44; Pp<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>28&#8211;30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41; or &#8220;ultraprotective&#8221; ventilation strategy &#40;Vt<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>ml&#47;kg ideal b&#46;w&#46;&#44; Pp<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>25<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41; in order to minimize ventilator-induced lung injury &#40;VILI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">9</span></a> Carbon dioxide removal &#40;ECCO<span class="elsevierStyleInf">2</span>R&#41; is simpler than VV ECMO&#44; and has been shown to lower the concentration of cytokines at pulmonary level &#40;in bronchoalveolar lavage &#91;BAL&#93;&#41; when ventilating with Vt<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>ml&#47;kg ideal b&#46;w&#46;&#44; thereby affording effective elimination of CO<span class="elsevierStyleInf">2</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> These systems effectively clear CO<span class="elsevierStyleInf">2</span> in patients with hypercapnia of different etiologies&#44; but also allow ultraprotective ventilation in patients with severe ARDS &#8211; the benefits of which remain to be determined&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">11</span></a> In the absence of VV ECMO or ECCO<span class="elsevierStyleInf">2</span>R&#44; we would be obliged to accept permissive hypercapnia and&#47;or hypoxemia levels that are not clearly established&#46; Nevertheless&#44; although this type of ventilation with VV ECMO or ECCO<span class="elsevierStyleInf">2</span>R appears promising&#44; no beneficial impact in terms of mortality has yet been established&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> and currently most centers place priority on weaning from extracorporeal devices versus weaning from the ventilator&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">There are no clinical evidence-based guidelines recommending a concrete form of ventilation in patients subjected to VV ECMO&#44; though 77&#37; of the centers with experience apply the &#8220;lung rest&#8221; concept&#44; with low Vt&#44; low respiratory frequency &#40;RF&#41;&#44; and high positive end-expiratory pressure &#40;PEEP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Ventilator-induced lung injury</span><p id="par0030" class="elsevierStylePara elsevierViewall">Ventilator-induced lung injury occurs at four levels&#46; The use of high plateau pressures induces barotrauma&#59; injury derived from ventilation with high Vt causes volutrauma&#59; and the activation of certain inflammatory processes in the alveolar endothelial and epithelial cells induced by aggressive MV gives rise to biotrauma&#46; Furthermore&#44; the cyclic opening and closing of the alveolar units produces atelectrauma&#8212;the latter being defined as the percentage of collapsed lung that opens at the end of inspiration and collapses again at the end of expiration&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The lung with ARDS is heterogeneous&#46; Studies involving thoracic computed tomography &#40;CT&#41; have demonstrated the existence of areas with collapsed alveoli in dependent zones and others with ventilated alveoli in non-dependent zones&#44; which are those that receive most of the Vt&#46; The use of protective ventilation with Vt 6<span class="elsevierStyleHsp" style=""></span>ml&#47;kg produces alveolar overdistension in almost 30&#37; of all cases of ARDS&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">1</span></a> Patients with ARDS and treated with ECMO are intensely hypoxemic&#44; with large zones of collapsed lung&#44; often affecting all four lung quadrants&#46; As a result&#44; the ventilated alveoli receive most of the Vt and are subject to overdistension despite the adoption of protective ventilation measures&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a> However&#44; it does not seem that Vt exclusively plays an important role in the development of VILI&#44; though we need regional and dynamic data on pulmonary ventilation and circulation in patients with ARDS in order to evaluate the application of different ventilation strategies&#46; In this regard&#44; and in addition to thoracic CT&#44; electrical impedance tomography &#40;EIT&#41; affords real-time visioning of regional ventilation and produces information about how the different ventilatory parameters affect the lung&#44; with a view to minimizing VILI&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">16</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The degree to which cyclic alveolar opening and closing&#44; and alveolar overdistension&#44; contribute to VILI is not clear&#46; A study involving patients with acute lung injury &#40;ALI&#41; and ARDS treated with high PEEP measured alveolar inflammatory activity using positron-emission tomography &#40;PET&#41; and alveolar distension with CT at the end of inspiration and at the end of expiration&#46; Inflammation in the ventilated lung regions and in the rest of the lung was related to Pp<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>26&#8211;27<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; though no association was found between metabolic activity and cyclic alveolar opening and closing&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">17</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The use of high PEEP to improve alveolar recruitment&#44; minimizing alveolar overdistension&#44; has not been shown to reduce mortality in patients with ARDS&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> In patients treated with ECMO&#44; the use of high PEEP &#40;&#62;10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41; in the first three days of extracorporeal support was independently correlated to a decrease in mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Therefore&#44; a protective ventilation strategy should always be adopted in patients with ARDS with or without ECMO&#44; though we do not know how to use PEEP for reducing VILI in these individuals&#44; where the existence of pulmonary heterogeneity is a fact&#46; The increase in PEEP protects the lungs&#44; provided it is accompanied by a change in lung mechanics&#44; i&#46;e&#46;&#44; the same Vt should result in improved respiratory compliance &#40;C<span class="elsevierStyleInf">RS</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> In this regard&#44; studies involving high PEEP have not demonstrated benefits in terms of survival&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">21</span></a> though PEEP has been shown to offer benefit in patients with increased lung recruitability&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">22</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">A decrease in driving pressure &#40;&#916;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Vt&#47;C<span class="elsevierStyleInf">RS</span>&#41; is the factor that has been associated to improved survival in ARDS patients&#44; considering that C<span class="elsevierStyleInf">RS</span> is closely related to the aerated lung volume&#44; i&#46;e&#46;&#44; functional lung size&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> Calculated as Pp-PEEP &#40;cmH<span class="elsevierStyleInf">2</span>O&#41;&#44; a decrease in &#916;<span class="elsevierStyleItalic">P</span> is associated to an improved prognosis&#44; while an increase is associated to a poorer prognosis&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Mode of mechanical ventilation with extracorporeal membrane oxygenation</span><p id="par0060" class="elsevierStylePara elsevierViewall">The MV mode to be used in patients subjected to ECMO has not been established&#44; and no comparative studies are available&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the different ventilation modes in patients subjected to VV ECMO&#44; according to the opinion of different expert sources&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In a recent international study involving 141 centers from 28 countries on all continents and belonging to the Extracorporeal Life Support Organization &#40;ELSO&#41;&#44; most of the centers &#40;62&#37;&#41; were seen to use controlled MV modes&#44; while only 27&#37; used assist modes in patients with VV ECMO&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> In the international study recently published by Camporota et al&#46;&#44; involving 133 surveyed centers&#44; the pressure control mode was used in 64&#46;4&#37; of the centers&#44; the pressure assist mode in 47&#46;3&#37;&#44; bilevel positive airway pressure &#40;BiPAP&#41; in 17&#46;1&#37;&#44; volume control mode in 11&#46;6&#37;&#44; airway pressure release ventilation &#40;APRV&#41; in 4&#46;6&#37;&#44; and neurally adjusted ventilatory assist &#40;NAVA&#41; and high-frequency ventilation in 1&#37; of the centers&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a> Lastly&#44; in a multicenter study in three hospitals in Australia and France&#44; 55&#37; of the patients subjected to ECMO &#40;VV ECMO the 98&#37; of the cases&#41; received pressure control modes&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In general&#44; pressure modes allow daily monitoring of Vt&#44; providing information on the improvement or worsening of lung compliance&#44; and make it possible to increase Vt to at least 6<span class="elsevierStyleHsp" style=""></span>ml&#47;kg for starting weaning from VV ECMO&#46; The inconvenience is that the limitation of Vt may prove difficult in assist mode&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a> The APRV mode requires spontaneous ventilation of the patient&#44; and may be an alternative to the pressure control mode in patients with spontaneous ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In the early stages of ARDS it is more difficult to maintain spontaneous ventilation&#44; and the patient is often under neuromuscular block&#46; After this phase&#44; spontaneous ventilation allows respiratory muscle and diaphragmatic training&#44; with a decrease in the sedation requirements&#44; though when poorly applied it can worsen patient-ventilator asynchrony&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">24</span></a> The NAVA mode in patients subjected to ECMO reduces patient-ventilator asynchrony in the lung function recovery phase&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Tidal volume and plateau pressure with extracorporeal membrane oxygenation</span><p id="par0080" class="elsevierStylePara elsevierViewall">Of the centers belonging to the ELSO&#44; and with regard to the Vt used&#44; 76&#37; claimed to ventilate their patients with Vt<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#44; while 21&#37; specified no Vt value during support with VV ECMO&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> In animals&#44; a reduction of Vt<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>ml&#47;kg ideal b&#46;w&#46; has been associated to a decrease in lung edema and injury&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> In the Xtravent multicenter study&#44; &#8220;ultraprotective ventilation&#8221; with ECCO<span class="elsevierStyleInf">2</span>R versus protective ventilation did not result in a decrease in the days of MV&#44; though a reduction of alveolar interleuking-6 levels was observed&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a> as previously reported&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">10</span></a> In the post hoc analysis&#44; in the group of patients with PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>150<span class="elsevierStyleHsp" style=""></span>mmHg&#44; a decrease was recorded in the days of MV in the group subjected to ECCO<span class="elsevierStyleInf">2</span>R &#40;40&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;8 vs 28&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;4&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;033&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">12</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">According to a recent systematic review involving 2042 patients in 49 studies&#44; the tendency is to use an &#8220;ultraprotective&#8221; strategy&#44; ventilating with Vt<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>ml&#47;kg in order to limit Pp to &#8804;30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46; This practice possibly reflects the impossibility of maintaining adequate ventilation without a risk of lung injury before starting extracorporeal support&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">26</span></a> In another international survey&#44; 31&#37; of the centers were seen to ventilate patients with ECMO using an &#8220;ultraprotective&#8221; strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">13</span></a> According to different studies&#44; the way in which we use MV during support with VV ECMO appears to have an impact upon mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">15&#44;26&#44;27</span></a> The study published by Pham et al&#46; shows the reduction of Pp on the first day of ECMO to be independently associated to lowered mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">28</span></a> Likewise&#44; in an international multicenter study&#44; one of the predictors of mortality in patients treated with ECMO was Pp<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O before introducing ECMO&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The Predicting death for severe ARDS on <span class="elsevierStyleSmallCaps">VV</span>-ECMO &#40;PRESERVE&#41; mortality risk score takes 8 pre-ECMO parameters into account in predicting the probability of survival in patients with severe ARDS treated with VV ECMO&#46; Patient age&#44; body mass index&#44; immunosuppression&#44; the use of prone decubitus&#44; the days of MV&#44; the SOFA score&#44; PEEP and Pp<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O were the calculated parameters&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">29</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">There are no recommendations on how to proceed in lowering Vt once VV ECMO support has been started&#46; A reduction in the first 1&#8211;3 days of support to &#60;4<span class="elsevierStyleHsp" style=""></span>ml&#47;kg ideal b&#46;w&#46; could be proposed&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">19</span></a> In a recent study&#44; only the parameter Pp<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>31<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O was associated to in-hospital survival&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Positive end-expiratory pressure with extracorporeal membrane oxygenation</span><p id="par0100" class="elsevierStylePara elsevierViewall">In patients with ARDS&#44; PEEP is used to maintain alveolar recruitment&#44; improve oxygenation and prevent VALI &#40;atelectrauma with cyclic alveolar opening and closing&#41;&#46; However&#44; alveolar overdistension and the increase in right ventricular afterload are deleterious effects of the indiscriminate use of PEEP&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The PEEP level to be used in patients treated with ECMO is subject to controversy&#46; The reduction of Vt&#44; particularly when &#8220;ultraprotective ventilation&#8221; is used &#40;Vt<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>ml&#47;kg ideal b&#46;w&#46;&#41;&#44; can produce atelectasis with worsening of the ventilation&#47;perfusion ratio&#46; The ELSO therefore recommends a PEEP level of 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; in contrast to the protocol established by Richard et al&#46; in the Consensus Conference&#44; where the recommendation is simply to use &#8220;minimum PEEP&#8221; for &#8220;minimum Pp&#8221; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Higher PEEP levels could cause alveolar overdistension&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">18</span></a> as well as reduce venous return in patients with VV ECMO and worsen right ventricular function in VA ECMO&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In patients with VV ECMO&#44; PEEP is not necessary to improve oxygenation&#44; except in intensely hypoxemic individuals or cases requiring high blood flows &#40;&#62;5<span class="elsevierStyleHsp" style=""></span>l&#47;min&#41; during support &#40;e&#46;g&#46;&#44; septic shock patients&#41;&#46; In contrast to VV ECMO&#44; the ECCO<span class="elsevierStyleInf">2</span>R systems require PEEP and FiO<span class="elsevierStyleInf">2</span> in the respirator in order to improve oxygenation&#44; since they operate with a much lower blood flow than VV ECMO&#44; and CO<span class="elsevierStyleInf">2</span> clearance is fundamentally dependent upon the flow of gas&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#44;31&#44;32</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In ECMO&#44; the use of high PEEP levels would favor alveolar recruitment&#44; which in turn could accelerate lung recovery through the prevention of capillary loss and macrophage activation generated in lung hypoxemic regions induced by the presence of atelectasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">10&#44;28&#44;33</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In an international survey involving 133 centers&#44; 63&#37; used a fixed PEEP level&#44; 21&#37; introduced adjustments according to compliance&#44; 9&#46;3&#37; did so according to the radiological findings&#44; and 7&#46;3&#37; introduced adjustments according to EIT&#46; In turn&#44; 34&#46;9&#37; of the centers used PEEP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; while 27&#46;9&#37; used PEEP levels below this value&#46; Only 15&#46;5&#37; used PEEP 15&#8211;20<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">33</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">As has been commented above&#44; in a retrospective study&#44; the use of PEEP<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O during the first three days of treatment with ECMO was associated to increased mortality&#46; On the other hand&#44; in a more recent retrospective study involving 62 patients&#44; a one-point PEEP increment was seen to be associated to a 36&#46;2&#37; decrease in the odds ratio for survival 30 days after discharge &#40;95&#37;CI 10&#46;8&#8211;54&#46;4&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41;&#40;PEEP survivors 8&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44; survivors 7&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">30</span></a> In patients exposed to increased overdistension&#44; the effect of PEEP may prove deleterious&#44; and in patients with more recruitable areas we could perhaps use higher PEEP levels&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">It therefore would be very difficult to recommend a PEEP level in these patients&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the different recommendations of groups of experts&#46; The latest ELSO guides warn that &#8220;in patients with respiratory failure and ECMO&#44; it could be a mistake to try to recruit lung volume in the early stages&#8221;&#46; This would speak in favor of the risk of pulmonary overdistension in certain patients&#44; recommending PEEP levels of between 5 and 15<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a> In the same sense&#44; according to the only European Consensus Conference on ECMO of 2014&#44; the recommendation for ventilating ARDS patients with ECMO would be to &#8220;adjust MV to minimize Pp while we apply minimum PEEP&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a> In patients with ARDS due to influenza A &#40;H1N1&#41;&#44; the <span class="elsevierStyleItalic">R&#233;seau Europeen de Recherche en Ventilation Artificielle</span> &#40;REVA&#41; recommended lowering Vt to maintain Pp<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>20&#8211;25<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; with the application of PEEP<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">As has been commented above&#44; driving pressure &#40;&#916;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>Pp<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>PEEP&#41; is the factor that has been associated to improved survival in ARDS patients&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">20</span></a> In patients with ECMO&#44; previous studies have shown high &#916;<span class="elsevierStyleItalic">P</span> to be associated to poorer survival&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">11&#44;19</span></a> In a recent study carried out to assess the association among the different ventilatory parameters during ECMO indicated for refractory hypoxemia in ARDS&#44; the authors concluded that increased &#916;<span class="elsevierStyleItalic">P</span> is the only ventilatory parameter during ECMO showing an independent association to in-hospital mortality in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">38</span></a> In this study&#44; Serpa-Neto et al&#46; included 545 patients from 9 studies&#44; where in addition to &#916;<span class="elsevierStyleItalic">P</span>&#44; advanced age&#44; the male sex and a low body mass index were also seen to be independently associated to mortality&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Respiratory frequency</span><p id="par0140" class="elsevierStylePara elsevierViewall">The RF to be used in patients subjected to ECMO has likewise not been established&#46; The ELSO recommended a low RF &#40;4&#8211;5<span class="elsevierStyleHsp" style=""></span>rpm&#41; to avoid mechanical lung &#8220;stress&#8221;&#44; though in general the range is between 4 and 30<span class="elsevierStyleHsp" style=""></span>rpm as evidenced by the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">15</span></a> In general&#44; the adjustment of RF aims to ensure maintenance of the arterial pH&#44; but this concept changes in patients subjected to VV ECMO&#44; where maintenance of the arterial pH and PaCO<span class="elsevierStyleInf">2</span> are directly dependent upon the flow of gas in the oxygenation membrane&#46; In this context&#44; PaCO<span class="elsevierStyleInf">2</span> is to be slowly reduced once support has been started&#44; with a gas&#47;blood flow of 1&#58;1 in ECMO&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">31&#44;32</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In a recent international survey&#44; 55&#37; of the centers ventilated their patients subjected to ECMO with a RF of 5&#8211;10<span class="elsevierStyleHsp" style=""></span>rpm&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">23</span></a> possibly reflecting a tendency to ventilate with lower RF as in the &#8220;lung rest&#8221; model proposed by Gattinoni et al&#46; years ago&#44; and in which ventilation with a low RF &#40;3&#8211;5<span class="elsevierStyleHsp" style=""></span>rpm&#41; and a low peak inspiratory pressure with an ECCO<span class="elsevierStyleInf">2</span>R system in patients suffering severe ARDS of pulmonary origin resulted in improved lung function in 72&#46;8&#37; of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">34</span></a> In this regard&#44; the latest recommendations of the ELSO are to &#8220;use MV with low parameters in order to allow lung rest&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Fraction of inspired O<span class="elsevierStyleInf">2</span> in patients with extracorporeal membrane oxygenation</span><p id="par0150" class="elsevierStylePara elsevierViewall">It is clear that in order to minimize VILI we must lower FiO<span class="elsevierStyleInf">2</span> to minimum levels&#44; with the purpose of maintaining SatpO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>80&#37; in VV ECMO&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">31</span></a> or between 84 and 88&#37; according to the different groups&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">35&#44;37</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="par0155" class="elsevierStylePara elsevierViewall">In patients with ARDS&#44; MV with the reduction of Pp has been shown to reduce mortality&#46; However&#44; there are no clear evidences&#44; guides or recommendations on how to ventilate patients subjected to ECMO&#46; A decrease in driving pressure has been associated to improved in-hospital survival among patients with severe ARDS treated with ECMO&#46; The monitoring of this MV parameter therefore could be recommended in the same way as in patients without ECMO&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Since extracorporeal systems oxygenate and clear CO<span class="elsevierStyleInf">2</span>&#44; protective and &#8220;ultraprotective&#8221; MV is possible&#44; and would allow a reduction of VILI in these patients&#46; The lowering of Vt &#40;&#60;4<span class="elsevierStyleHsp" style=""></span>ml&#47;kg ideal b&#46;w&#46;&#41;&#44; Pp &#40;&#60;25<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41;&#44; PEEP &#40;5&#8211;15<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41; and RF allows us to maintain lung rest&#44; avoiding alveolar overdistension&#44; biotrauma and atelectrauma&#46; Further studies are needed to demonstrate the impact of this ventilatory strategy upon the mortality of patients with severe ARDS treated with VV ECMO or ECCO<span class="elsevierStyleInf">2</span>R systems&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">There are no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Ventilator-induced lung injury"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Mode of mechanical ventilation with extracorporeal membrane oxygenation"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Tidal volume and plateau pressure with extracorporeal membrane oxygenation"
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        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Positive end-expiratory pressure with extracorporeal membrane oxygenation"
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          "identificador" => "sec0030"
          "titulo" => "Respiratory frequency"
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          "identificador" => "sec0035"
          "titulo" => "Fraction of inspired O in patients with extracorporeal membrane oxygenation"
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          "titulo" => "Conclusions"
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          "identificador" => "sec0045"
          "titulo" => "Conflicts of interest"
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          "identificador" => "xack315030"
          "titulo" => "Acknowledgements"
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          "titulo" => "References"
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    "fechaRecibido" => "2016-11-07"
    "fechaAceptado" => "2016-12-14"
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          "clase" => "keyword"
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          "palabras" => array:10 [
            0 => "Mechanical ventilation"
            1 => "Acute respiratory distress syndrome"
            2 => "Extracorporeal membrane oxygenation"
            3 => "Venovenous extracorporeal membrane oxygenation"
            4 => "Lung rest"
            5 => "Protective ventilation"
            6 => "Ultraprotective ventilation"
            7 => "Ventilator induced lung injury"
            8 => "Extracorporeal CO<span class="elsevierStyleInf">2</span> removal"
            9 => "Driving pressure"
          ]
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      ]
      "es" => array:1 [
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec907602"
          "palabras" => array:10 [
            0 => "Ventilaci&#243;n mec&#225;nica"
            1 => "S&#237;ndrome de distr&#233;s respiratorio agudo"
            2 => "Membrana de oxigenaci&#243;n extracorp&#243;rea"
            3 => "Membrana de oxigenaci&#243;n extracorp&#243;rea venovenosa"
            4 => "<span class="elsevierStyleItalic">Lung rest</span>"
            5 => "Ventilaci&#243;n protectora"
            6 => "Ventilaci&#243;n ultraprotectora"
            7 => "Lesi&#243;n pulmonar asociada a ventilaci&#243;n mec&#225;nica"
            8 => "Sistemas depuradores de carb&#243;nico"
            9 => "Driving pressure"
          ]
        ]
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mechanical ventilation &#40;MV&#41; is a crucial element in the management of acute respiratory distress syndrome &#40;ARDS&#41;&#44; because there is high level evidence that a low tidal volume of 6<span class="elsevierStyleHsp" style=""></span>ml&#47;kg &#40;protective ventilation&#41; improves survival&#46; In these patients with refractory respiratory insufficiency&#44; venovenous extracorporeal membrane oxygenation &#40;ECMO&#41; can be used&#46; This salvage technique improves oxygenation&#44; promotes CO<span class="elsevierStyleInf">2</span> clearance&#44; and facilitates protective and ultraprotective MV&#44; potentially minimizing ventilation-induced lung injury&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Although numerous trials have investigated different ventilation strategies in patients with ARDS&#44; consensus is lacking on the optimal MV settings during venovenous ECMO&#46; Although the concept of &#8220;lung rest&#8221; was introduced years ago&#44; there are no evidence-based guidelines on its use in application to MV in patients supported by ECMO&#46; How MV in ECMO patients can promote lung recovery and weaning from ventilation is not clear&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The purpose of this review is to describe the ventilation strategies used during venovenous ECMO in clinical practice&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La ventilaci&#243;n mec&#225;nica &#40;VM&#41; es clave en el manejo del s&#237;ndrome de distr&#233;s respiratorio del adulto &#40;SDRA&#41; ya que existe un alto nivel de evidencia de que la ventilaci&#243;n con vol&#250;menes tidales de 6<span class="elsevierStyleHsp" style=""></span>ml&#47;kg &#40;ventilaci&#243;n protectora&#41; mejora la supervivencia&#46; La oxigenaci&#243;n con membrana extracorp&#243;rea &#40;ECMO&#41; veno-venosa es una terapia de rescate en el tratamiento de la insuficiencia respiratoria refractaria que mejora la oxigenaci&#243;n&#44; reduce el CO<span class="elsevierStyleInf">2</span> y facilita la aplicaci&#243;n de VM protectora&#44; reduciendo potencialmente la lesi&#243;n pulmonar asociada a VM&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Aunque las estrategias ventilatorias en pacientes con SDRA han sido analizadas en numerosos estudios&#44; no existe consenso respecto a c&#243;mo ventilar a pacientes con ECMO veno-venosa&#46; El concepto de <span class="elsevierStyleItalic">&#171;lung rest&#187;</span>&#44; introducido hace a&#241;os&#44; carece a&#250;n de evidencias para recomendar su uso pero podr&#237;a promover la recuperaci&#243;n pulmonar y facilitar el destete de la VM&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El objetivo de esta revisi&#243;n es describir las diferentes estrategias de ventilaci&#243;n en pacientes tratados con ECMO veno-venosa&#46;</p></span>"
      ]
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    "NotaPie" => array:1 [
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; L&#243;pez Sanchez M&#46; Ventilaci&#243;n mec&#225;nica en pacientes tratados con membrana de oxigenaci&#243;n extracorp&#243;rea &#40;ECMO&#41;&#46; Med Intensiva&#46; 2017&#59;41&#58;491&#8211;496&#46;</p>"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">PEEP&#58; positive end-expiratory pressure&#59; Pp&#58; plateau pressure&#59; FiO<span class="elsevierStyleInf">2</span>&#58; inspired fraction of oxygen&#59; RF&#58; respiratory frequency&#59; REVA&#58; <span class="elsevierStyleItalic">R&#233;seau Europeen de Recherche en Ventilation Artificielle</span>&#59; PCV&#58; pressure control ventilation&#59; VCV&#58; volume control ventilation&#59; MV&#58; mechanical ventilation&#59; Vt&#58; tidal volume&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Source&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MV objective&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MV mode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Vt&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PEEP &#40;cmH<span class="elsevierStyleInf">2</span>O&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RF &#40;rpm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FiO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ELSO guides 2013<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">35</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung rest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PCV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">European Network of MV &#40;REVA&#41;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">37</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung rest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">VCV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8804;20&#8211;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;3&#8211;0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Consensus Conference ECMO<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">36</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lung rest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">&#8211;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleBold">&#8211;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Minimize Pp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Minimum PEEP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8211;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleBold">&#8211;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Mechanical ventilation in VV ECMO according to the opinion of different expert sources&#46;</p>"
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                  "referenciaCompleta" => "R&#233;seau Europeen de Recherche en Ventilation Artificielle &#40;REVA&#41;&#46; Syndrome de D&#233;tresse Respiratoire Aigu&#235; li&#233; &#224; la grippe A &#40;H1N1&#41;-2009 Recommendations pour l&#225;ssistance respiratoire&#46; Available from&#58; <a href="http://www.revaweb.org/">http&#58;&#47;&#47;www&#46;revaweb&#46;org</a> &#91;accessed September 2016&#93;&#46;"
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                      "titulo" => "Associations between ventilator settings during extracorporeal membrane oxygenation for refractory hypoxemia and outcome in patients with acute respiratory distress syndrome&#58; a pooled individual patient data analysis"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "the ReVA Research Network and the PROVE Network Investigators"
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                            0 => "A&#46; Serpa Neto"
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                            2 => "L&#46;C&#46; Azevedo"
                            3 => "Bein Th"
                            4 => "L&#46; Brochard"
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    ]
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2017.08.006

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2024 November	5	5	10
2024 October	109	67	176
2024 September	115	44	159
2024 August	166	61	227
2024 July	154	38	192
2024 June	129	55	184
2024 May	120	44	164
2024 April	105	61	166
2024 March	127	49	176
2024 February	138	65	203
2024 January	134	59	193
2023 December	130	57	187
2023 November	137	65	202
2023 October	136	61	197
2023 September	168	50	218
2023 August	130	38	168
2023 July	71	44	115
2023 June	61	36	97
2023 May	72	50	122
2023 April	86	58	144
2023 March	196	60	256
2023 February	118	53	171
2023 January	89	50	139
2022 December	128	67	195
2022 November	139	69	208
2022 October	121	84	205
2022 September	76	75	151
2022 August	81	67	148
2022 July	56	65	121
2022 June	64	57	121
2022 May	74	71	145
2022 April	82	98	180
2022 March	103	148	251
2022 February	99	92	191
2022 January	129	103	232
2021 December	136	128	264
2021 November	110	111	221
2021 October	141	135	276
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2021 August	96	100	196
2021 July	97	78	175
2021 June	158	97	255
2021 May	150	117	267
2021 April	464	240	704
2021 March	292	202	494
2021 February	195	114	309
2021 January	194	106	300
2020 December	198	103	301
2020 November	197	118	315
2020 October	113	81	194
2020 September	128	83	211
2020 August	137	76	213
2020 July	152	96	248
2020 June	136	69	205
2020 May	212	117	329
2020 April	223	102	325
2020 March	77	53	130
2020 February	270	125	395
2020 January	116	104	220
2019 December	155	92	247
2019 November	124	105	229
2019 October	162	111	273
2019 September	164	121	285
2019 August	138	87	225
2019 July	89	70	159
2019 June	162	81	243
2019 May	119	113	232
2019 April	145	93	238
2019 March	635	94	729
2019 February	112	100	212
2019 January	87	69	156
2018 December	103	87	190
2018 November	123	136	259
2018 October	129	41	170
2018 September	164	46	210
2018 August	81	29	110
2018 July	40	22	62
2018 June	34	14	48
2018 May	20	18	38
2018 April	40	27	67
2018 March	35	11	46
2018 February	0	1	1
2017 December	0	1	1
2017 November	3	1	4
2017 October	0	1	1
2017 September	0	1	1

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