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. 2021 Jun 29;3(7):e0461.
doi: 10.1097/CCE.0000000000000461. eCollection 2021 Jul.

Individualized Multimodal Physiologic Approach to Mechanical Ventilation in Patients With Obesity and Severe Acute Respiratory Distress Syndrome Reduced Venovenous Extracorporeal Membrane Oxygenation Utilization

Francesco Zadek  1 , Jonah Rubin  2 , Luigi Grassi  1 , Daniel Van Den Kroonenberg  1 , Grant Larson  1 , Martin Capriles  1 , Roberta De Santis Santiago  1 , Gaetano Florio  1 , David A Imber  1 , Edward A Bittner  1 , Kathryn A Hibbert  2 , Alex Legassey  3 , Jeliene LaRocque  3 , Gaston Cudemus-Deseda  1 , Aranya Bagchi  1 , Jerome Crowley  1 , Kenneth Shelton  1 , Robert Kacmarek  1   3 , Lorenzo Berra  1   3
Affiliations

Individualized Multimodal Physiologic Approach to Mechanical Ventilation in Patients With Obesity and Severe Acute Respiratory Distress Syndrome Reduced Venovenous Extracorporeal Membrane Oxygenation Utilization

Francesco Zadek et al. Crit Care Explor. .

Abstract

Objective: To investigate whether individualized optimization of mechanical ventilation through the implementation of a lung rescue team could reduce the need for venovenous extracorporeal membrane oxygenation in patients with obesity and acute respiratory distress syndrome and decrease ICU and hospital length of stay and mortality.

Design: Single-center, retrospective study at the Massachusetts General Hospital from June 2015 to June 2019.

Patients: All patients with obesity and acute respiratory distress syndrome who were referred for venovenous extracorporeal membrane oxygenation evaluation due to hypoxemic respiratory failure.

Intervention: Evaluation and individualized optimization of mechanical ventilation by the lung rescue team before the decision to proceed with venovenous extracorporeal membrane oxygenation. The control group was those patients managed according to hospital standard of care without lung rescue team evaluation.

Measurement and main results: All 20 patients (100%) allocated in the control group received venovenous extracorporeal membrane oxygenation, whereas 10 of 13 patients (77%) evaluated by the lung rescue team did not receive venovenous extracorporeal membrane oxygenation. Patients who underwent lung rescue team evaluation had a shorter duration of mechanical ventilation (p = 0.03) and shorter ICU length of stay (p = 0.03). There were no differences between groups in in-hospital, 30-day, or 1-year mortality.

Conclusions: In this hypothesis-generating study, individualized optimization of mechanical ventilation of patients with acute respiratory distress syndrome and obesity by a lung rescue team was associated with a decrease in the utilization of venovenous extracorporeal membrane oxygenation, duration of mechanical ventilation, and ICU length of stay. Mortality was not modified by the lung rescue team intervention.

Keywords: acute respiratory distress syndrome; mechanical power; mechanical ventilation; obesity; recruitment maneuver; venovenous extracorporeal membrane oxygenation.

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Conflict of interest statement

Dr. Kacmarek is a consultant for Medtronic and Orange Med and has received research grants from Medtronic and Venner Medical (Danischenhagen, Germany). Dr. Berra receives salary support from K23 HL128882/National Heart, Lung, and Blood Institute National Institutes of Health as principal investigator for his work on hemolysis and nitric oxide. He receives technologies and devices from inhaled nitric oxide (iNO) Therapeutics LLC, Praxair Inc., Masimo Corp. he receives grants from “Fast Grants for COVID-19 research” at Mercatus Center of George Mason University and from iNO Therapeutics LLC. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1.
Figure 1.
The flow chart shows the clinical pathways of a patient with obesity affected by severe acute respiratory disease. Standard-of-care cohort: patients with obesity and acute respiratory distress syndrome (ARDS) were ventilated according to a protocol-based approach (i.e., ARDS network [ARDSnet] protocol and best tidal compliance). When the patient’s lung function deteriorated and the extracorporeal membrane oxygenation (ECMO) Extracorporeal Life Support Organization criteria (20) for VV ECMO were met, the ECMO team started venovenous ECMO. Lung rescue team (LRT) cohort: the LRT was activated together with the ECMO team when a patient with obesity and severe acute respiratory distress syndrome (ARDS) was a candidate for ECMO. Additional criteria to request the LRT consult included the following: 1) patients with class III obesity (i.e., body mass index > 40 kg/m2) and progressive acute respiratory failure not improving in the first 24 hr of ventilation despite strict compliance to best-practice ventilation protocols; 2) patients with severe ARDS and refractory hypoxemia (i.e., Pao2 < 60 mm Hg, Fio2 0.8–1.0, and a positive end-expiratory pressure [PEEP] > 10 cm H2O for > 12–24 hr). Unlike the standard practice, the LRT followed an individualized multimodal physiologic approach to guide ventilation of the patients. At the end of the consultation, the clinical team decided whether to proceed or to hold ECMO cannulation. (A) esophageal manometry, (B) advanced lung mechanics measurements, (C) transthoracic heart ultrasound, (D) electrical impedance tomography.
Figure 2.
Figure 2.
The flow chart summarizes the main procedure for positive end-expiratory pressure (PEEP) titration. End-expiratory transpulmonary pressure was calculated as the difference between total PEEP (PEEP set on ventilator + auto-PEEP) and end-expiratory esophageal pressure.
Figure 3.
Figure 3.
Synoptic panel summarizing the main lung mechanic measurements. A, Positive end-expiratory pressure trends along the first 5 d; (B) tidal volume trends along the first 5 d; (C) compliance trends along the first 5 d; (D) driving pressure trends along the first 5 d; (E) expired minute ventilation trends along the first 5 d; (F) mechanical power trends along the first 5 d. *Within-subjects analysis versus pre consultation p < 0.05. $Between-subjects analysis p < 0.05.
See this image and copyright information in PMC

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