Biotrauma during ultra-low tidal volume ventilation and venoarterial extracorporeal membrane oxygenation in cardiogenic shock: a randomized crossover clinical trial

Annals of Intensive Care

Miguel Arias-Guillén¹  Luigi Camporota²  Covadonga Huidobro³  Inés López-Alonso³  Cecilia López-Martínez³  Paula Martín-Vicente⁴  Juan Mayordomo-Colunga⁵  Arthur S. Slutsky⁶  Cecilia Del Busto⁷  Rodrigo Albillos-Almaraz⁷  Diego Parra⁷  Laura Amado-Rodríguez⁸  Guillermo M. Albaiceta⁹ 

[1] Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain;Servicio de Neumología, Hospital Universitario Central de Asturias, Oviedo, Spain;Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, King’s College, London, UK;Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain;Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain;Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain;Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain;Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias (IUOPA), Universidad de Oviedo, Oviedo, Spain;Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain;Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain;Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Central de Asturias, Oviedo, Spain;Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Canada;Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avda de Roma s/n, 33011, Oviedo, Spain;Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain;Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avda de Roma s/n, 33011, Oviedo, Spain;Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain;Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain;Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avda de Roma s/n, 33011, Oviedo, Spain;Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain;Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain;Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias (IUOPA), Universidad de Oviedo, Oviedo, Spain;

关键词: Extracorporeal membrane oxygenation;    Ventilator-induced lung injury;    Mechanical ventilation;    Pulmonary oedema;    Respiratory mechanics;   

DOI  :  10.1186/s13613-021-00919-0

来源: Springer

【 摘 要 】

BackgroundCardiogenic pulmonary oedema (CPE) may contribute to ventilator-associated lung injury (VALI) in patients with cardiogenic shock. The appropriate ventilatory strategy remains unclear. We aimed to evaluate the impact of ultra-low tidal volume ventilation with tidal volume of 3 ml/kg predicted body weight (PBW) in patients with CPE and veno–arterial extracorporeal membrane oxygenation (V–A ECMO) on lung inflammation compared to conventional ventilation.MethodsA single-centre randomized crossover trial was performed in the Cardiac Intensive Care Unit (ICU) at a tertiary university hospital. Seventeen adults requiring V–A ECMO and mechanical ventilation due to cardiogenic shock were included from February 2017 to December 2018. Patients were ventilated for two consecutive periods of 24 h with tidal volumes of 6 and 3 ml/kg of PBW, respectively, applied in random order. Primary outcome was the change in proinflammatory mediators in bronchoalveolar lavage fluid (BALF) between both ventilatory strategies.ResultsVentilation with 3 ml/kg PBW yielded lower driving pressures and end-expiratory lung volumes. Overall, there were no differences in BALF cytokines. Post hoc analyses revealed that patients with high baseline levels of IL-6 showed statistically significant lower levels of IL-6 and IL-8 during ultra-low tidal volume ventilation. This reduction was significantly proportional to the decrease in driving pressure. In contrast, those with lower IL-6 baseline levels showed a significant increase in these biomarkers.ConclusionsUltra-low tidal volume ventilation in patients with CPE and V–A ECMO may attenuate inflammation in selected cases. VALI may be driven by an interaction between the individual proinflammatory profile and the mechanical load overimposed by the ventilator.Trial registration The trial was registered in ClinicalTrials.gov (identifier NCT03041428, Registration date: 2nd February 2017).

【 授权许可】

CC BY