CCCF ePoster library. Gomes B. 11/12/19; 283442; EP54
Bruno Gomes
Bruno Gomes
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Topic: Basic or Translational Science

Gomes, Bruno1,2,7; Ribeiro, Rafela1,2,7; Ramadan, Khaled1,2,7; Galasso, Marcos1,2,7; Ali, Aadil1,2,7; Watanabe, Yui1,2,7; Paradiso, Emanuela2,7; Meineri, Massimiliano2,47; Chan, Harley2,4,7; Qaqish, Robert1,2,7; Zhang, Zhang1,2,7; Hwang, David5,7; Slutsky, Arthur3,6,7; Fan Eddy2,3,7; Liu, Mingyao1,2,7; Keshavjee, Shaf1,2,7; Cypel, Marcelo1,2,7; Del Sorbo, Lorenzo1,2,3,7.
(1Latner Thoracic Laboratories, University Health Network, Toronto, Canada, University Health Network, Toronto, Canada, 3Interdepartmental Division of Critical Care Medicine, Toronto, Canada, 4Guided Therapeutics- TECHNA Institute, Toronto, Canada, 5Laboratory Medicine and Molecular Diagnostics Sunnybrook Health Sciences Centre, Toronto, Canada,6St Michael's Hospital, TorontoCanada,7University of Toronto, Toronto, Canada) 

Introduction/Background: Extracorporeal membrane oxygenation with veno-venous configuration (VV-ECMO) is an effective intervention to improve gas exchange in patients with severe respiratory failure refractory to conventional treatments1. However, the ability to show improved outcomes with VV-ECMO in randomized controlled trials has been very problematic also due to the lack of standardized mechanical ventilation (MV)2strategies during VV-ECMO to minimize ventilator-induced lung injury (VILI)3. While there is general consensus in minimizing tidal ventilation4, the potential benefit of high positive end-expiratory pressure (PEEP) strategies remains unclear3. As MV provides limited contribution to gas exchange duringECMO, high PEEP is no longer required to improve oxygenation or reduce the impact of regional alveolar stress and strain implicated by MV. Hence, it is unknown whether optimizing alveolar recruitment with PEEP is functional in optimizing cardiopulmonary interaction and reducing the severity of lung injury.
ObjectivesIn a large animal model of ARDS supported with VV-ECMO to maintain adequate gas exchange we studied whether PEEP-induced alveolar recruitment reduces lung injury in comparison to atelectatic lungs.
Methods: Lung injury was induced by two serial bronchoscopic instillations of gastric juice to achieve a P/F ratio <100mmHg in anesthetized and paralyzed pigs supported with mechanical ventilationand VV-ECMO. The animals were then randomized to receive PEEP 20 cmH2O(n=4 HP) or 5 cmH2O(n=5 LP), with 5 cmH2Oof driving pressure. Lung and cardiac function were monitored for 5 hours. W/D ratio of the dependent and non-dependent lung areas and change in plasma IL-6 concentration over time were measured as markers of lung injury. 
Results: During VV-ECMO, gas exchange and hemodynamic parameters remained stable without significant differences in the two groups, despite the very low tidal volume delivered (HP 54 ml ±9; LP 41 ml ±11). Lung volume was higher in the HP compared with the LP group and remained unchanged after 5 hours. At the end of the experiment, the W/D of the dependent lung areas was significantly higher in the HP compared to LP group (HP 11.1, 95%CI: 10.5-11.7; LP 9.2, 95%CI:8.2-10.3); the W/D of the non-dependent lung areas was instead significantly higher in the LP compared to HP group (LP 6.3, 95%CI:5.6-6.9; HP 5.3, 95%CI:4.9-5.8). Plasma IL-6 increased over time after injury significantly more in the LP compared to the HP group (see figure). 
Conclusions: During VV-ECMO for ARDS mechanical ventilation with low PEEP results in a more homogeneous distribution of edema compared to high PEEP strategy, suggesting a more homogenous distribution of lung perfusion. However, HP resulted in lower systemic inflammation. Further analysis is required to assess the impact of alveolar recruitment on lung injury.


1.Combes A, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med 2018
2. Marhong JD, et al. Mechanical ventilation during extracorporeal membrane oxygenation: An international survey. Ann Am Thorac Soc 2014
3.Del Sorbo L, et al. Setting mechanical ventilation in ards patients during vv-ecmo: Where are we? Minerva Anestesiol 2015 
4.Araos J, et al. Near-apneic ventilation decreases lung injury and fibroproliferation in an ards model with ecmo. Am J Respir Crit Care Med 2018

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