Log in | Register

Lower tidal volume strategy (≈3 ml/kg) combined with extracorporeal CO2 removal versus ‘conventional’ protective ventilation (6 ml/kg) in severe ARDS : The prospective randomized Xtravent-studyOpen access

Thomas Bein| Steffen Weber-Carstens| Anton Goldmann| Thomas Müller| Thomas Staudinger| Jörg Brederlau| Ralf Muellenbach| Rolf Dembinski| Bernhard M. Graf| Marlene Wewalka| Alois Philipp| Klaus-Dieter Wernecke| Matthias Lubnow| Arthur S. Slutsky
Original
Volume 39, Issue 5 / May , 2013

Pages 847 - 856

Abstract

Background

Acute respiratory distress syndrome is characterized by damage to the lung caused by various insults, including ventilation itself, and tidal hyperinflation can lead to ventilator induced lung injury (VILI). We investigated the effects of a low tidal volume (VT) strategy (VT ≈ 3 ml/kg/predicted body weight [PBW]) using pumpless extracorporeal lung assist in established ARDS.

Methods

Seventy-nine patients were enrolled after a ‘stabilization period’ (24 h with optimized therapy and high PEEP). They were randomly assigned to receive a low VT ventilation (≈3 ml/kg) combined with extracorporeal CO2 elimination, or to a ARDSNet strategy (≈6 ml/kg) without the extracorporeal device. The primary outcome was the 28-days and 60-days ventilator-free days (VFD). Secondary outcome parameters were respiratory mechanics, gas exchange, analgesic/sedation use, complications and hospital mortality.

Results

Ventilation with very low VT’s was easy to implement with extracorporeal CO2-removal. VFD’s within 60 days were not different between the study group (33.2 ± 20) and the control group (29.2 ± 21, p = 0.469), but in more hypoxemic patients (PaO2/FIO2 ≤150) a post hoc analysis demonstrated significant improved VFD-60 in study patients (40.9 ± 12.8) compared to control (28.2 ± 16.4, p = 0.033). The mortality rate was low (16.5 %) and did not differ between groups.

Conclusions

The use of very low VT combined with extracorporeal CO2 removal has the potential to further reduce VILI compared with a ‘normal’ lung protective management. Whether this strategy will improve survival in ARDS patients remains to be determined (Clinical trials NCT 00538928).

Keywords

References

  1. Ware LB, Matthay MA (2000) The acute respiratory distress syndrome. N Engl J Med 342:1334–1337
    • View reference on PubMed
    • View reference on publisher's website
  2. Terragni PP, Rosboch G, Tealdi A, Corno E, Menaldo E, Davini O, Gandini G, Herrmann P, Mascia L, Quintel M, Slutsky AS, Gattinoni L, Ranieri VM (2007) Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med 175:160–166
    • View reference on PubMed
    • View reference on publisher's website
  3. Grasso S, Stripoli T, Sacchi M, Sacchi M, Trerotoli P, Staffieri F, Franchini D, De Monte V, Valentini V, Pugliese P, Crovace A, Driessen B, Fiore T (2009) Inhomogeneity of lung parenchyma during the open lung strategy: a computed tomography scan study. Am J Respir Crit Care Med 180:415–423
    • View reference on PubMed
    • View reference on publisher's website
  4. The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volume as compared with traditional tidal volume for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308
    • View reference on publisher's website
  5. Hager DN, Krishnan JA, Hayden DL, Hayden DL, Brower RG, ARDS Clinical Trials Network (2005) Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Am J Respir Crit Care Med 172:1241–1245
    • View reference on PubMed
    • View reference on publisher's website
  6. Grasso S, Stripoli T, De Michele M, Bruno F, Moschetta M, Angelelli G, Munno I, Ruggiero V, Anaclerio R, Cafarelli A, Driessen B, Fiore T (2007) ARDSNet ventilatory protocol and alveolar hyperinflation: role of positive end-expiratory pressure. Am J Respir Crit Care Med 176:761–767
    • View reference on PubMed
    • View reference on publisher's website
  7. Azzam ZS, Sharabi K, Guetta J, Bank EM, Gruenbaum Y (2010) The physiological and molecular effects of elevated CO2 levels. Cell Cycle 15:1528–1532
    • View reference on publisher's website
  8. Peltekova V, Engelberts D, Otulakowski G, Otulakowski G, Uematsu S, Post M, Kavanagh BP (2010) Hypercapnic acidosis in ventilator-induced lung injury. Intensive Care Med 36:869–878
  9. Rubenfeld GD, Cooper C, Greg Carter RT, Thompson BT, Hudson LD (2004) Barriers to providing lung-protective ventilation to patients with acute lung injury. Crit Care Med 32:1289–1293
    • View reference on PubMed
    • View reference on publisher's website
  10. Bein Th, Weber F, Philipp A, Prasser C, Pfeifer M, Schmid FX, Butz B, Birnbaum D, Taeger K, Schlitt HJ (2006) A new pumpless extracorporeal interventional lung assist in critical hypoxemia/hypercapnia. Crit Care Med 34:1372–1379
    • View reference on PubMed
    • View reference on publisher's website
  11. Terragni PP, Del Sorbo L, Mascia L, Urbino R, Martin EL, Birocco A, Faggiano C, Quintel M, Gattinoni L, Ranieri VM (2009) Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal. Anesthesiology 111:826–835
    • View reference on PubMed
    • View reference on publisher's website
  12. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, LeGall JR, Morris A, Spragg R (1994) American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824
    • View reference on PubMed
    • View reference on publisher's website
  13. Villar J, Pérez-Méndez L, López J, Belda J, Blanco J, Saralegui I, Suárez-Sipmann F, López J, Lubillo S, Kacmarek RM, HELP Network (2007) An early PEEP/FIO2 trial identifies different degrees of lung injury in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 176:795–804
    • View reference on PubMed
    • View reference on publisher's website
  14. ESICM Systematic Review Group (Ed.) (2011) Clinical evidence in intensive care. Medizinisch Wissenschaftliche Verlagsgesellschaft, Berlin, Germany
  15. Zimmermann M, Bein T, Arlt M, Philipp A, Rupprecht L, Mueller T, Lubnow M, Graf BM, Schlitt HJ (2009) Pumpless extracorporeal interventional lung assist in patients with acute respiratory distress syndrome: a prospective pilot study. Crit Care 13:R10
    • View reference on PubMed
    • View reference on publisher's website
  16. Brower RG, Lanken PN, Macintyre N, Matthay MA, Morris A, Ancukiewicz M, Schoenfeld D, Thompson BT, National Heart, Lung, and Blood Institute ARDS Clinical Trials Network (2004) Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 351:327–336
    • View reference on PubMed
    • View reference on publisher's website
  17. Schoenfeld DA, Bernard GR, ARDS Network (2002) Statistical evaluation of ventilator-free days as an efficacy measure in clinical trials of treatments for acute respiratory distress syndrome. Crit Care Med 30:1772–1777
    • View reference on PubMed
    • View reference on publisher's website
  18. Brunner E, Domhof S, Langer F (eds) (2002) Nonparametric analysis of longitudinal data in factorial experiments. Wiley, New York
  19. Aurigemma NM, Feldman NT, Gottlieb M, Ingram RH Jr, Lazarus JM, Lowrie EG (1977) Arterial oxygenation during hemodialysis. N Engl J Med 297:871–873
    • View reference on PubMed
    • View reference on publisher's website
  20. Gattinoni L, Kolobow T, Tomlinson T, Iapichino G, Samaja M, White D, Pierce J (1978) Low-frequency positive pressure ventilation with extracorporeal carbon dioxide removal (LFPPV-ECCO2R): an experimental study. Anesth Analg 57:470–477
    • View reference on PubMed
    • View reference on publisher's website
  21. Frank JA, Gutierrez JA, Jones KD, Allen L, Dobbs L, Matthay MA (2002) Low tidal volume reduces epithelial and endothelial injury in acid-injured rat lungs. Am J Respir Crit Care Med 165:242–249
    • View reference on PubMed
    • View reference on publisher's website
  22. Chiumello D, Carlesso E, Cadringher P, Caironi P, Valenza F, Polli F, Tallarini F, Cozzi P, Cressoni M, Colombo A, Marini JJ, Gattinoni L (2008) Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med 178:346–355
    • View reference on PubMed
    • View reference on publisher's website
  23. Bruhn A, Bugedo D, Riquelme F, Varas J, Retamal J, Besa C, Cabrera C, Bugedo G (2011) Tidal volume is a major determinant of cyclic recruitment-derecruitment in acute respiratory distress syndrome. Minerva Anestesiol 77:418–426
    • View reference on PubMed
  24. Caironi P, Cressoni M, Chiumello D, Ranieri M, Quintel M, Russo SG, Cornejo R, Bugedo G, Carlesso E, Russo R, Caspani L, Gattinoni L (2010) Lung opening and closing during ventilation of acute respiratory distress syndrome. Am J Respir Crit Care Med 181:578–586
    • View reference on PubMed
    • View reference on publisher's website
  25. Plataki M, Hubmayr RD (2010) The physical basis of ventilator-induced lung injury. Expert Rev Respir Med 4:373–385
    • View reference on PubMed
    • View reference on publisher's website
  26. Putensen C, Muders T, Kreyer S, Wrigge H (2008) Lung protective ventilation—protective effect of adequate supported spontaneous breathing [article in German]. Anaesthesiol Intensivmed Notfallmed Schmerzther 43:456–462
    • View reference on publisher's website
  27. Weber-Carstens S, Bercker S, Hommel M, Deja M, MacGuill M, Dreykluft C, Kaisers U (2009) Hypercapnia in late-phase ALI/ADS: providing spontaneous breathing using pumpless extracorporeal lung assist. Intensive Care Med 35:1100–1105
  28. Karagiannidis C, Lubnow M, Philipp A, Riegger GA, Schmid C, Pfeifer M, Mueller T (2010) Autoregulation of ventilation with neurally adjusted ventilatory assist on extracorporeal lung support. Intensive Care Med 36:2038–2044
  29. Dembinski R, Hochhausen N, Terbeck S, Uhlig S, Dassow C, Schneider M, Schachtrupp A, Henzler D, Rossaint R, Kuhlen R (2007) Pumpless extracorporeal lung assist for protective mechanical ventilation in experimental lung injury. Crit Care Med 35:2359–2366
    • View reference on PubMed
    • View reference on publisher's website
  30. Nierhaus A, Frings DP, Braune S, Baumann HJ, Schneider C, Wittenburg B, Kluge S (2011) Interventional lung assist enables lung protective mechanical ventilation in acute respiratory distress syndrome. Minerva Anestesiol 77:797–801
    • View reference on PubMed
  31. Gattinoni L, Carlesso E, Langer T (2012) Towards ultraprotective mechanical ventilation. Curr Opin Anesthesiol 25:141–147
    • View reference on publisher's website
  32. Müller T, Philipp A, Luchner A, Karagiannidis C, Bein T, Hilker M, Rupprecht L, Langgartner J, Zimmermann M, Arlt M, Wenger J, Schmid C, Riegger GA, Pfeifer M, Lubnow M (2009) A new miniaturized system for extracorporeal membrane oxygenation in adult respiratory failure. Crit Care 13:R205
    • View reference on PubMed
    • View reference on publisher's website

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement