@article {Friedman271, author = {Matthew L Friedman and Ryan P Barbaro and Melania M Bembea and Brian C Bridges and Ranjit S Chima and Todd J Kilbaugh and Poornima Pandiyan and Renee M Potera and Elizabeth A Rosner and Hitesh S Sandhu and James E Slaven and Keiko M Tarquinio and Ira M Cheifetz}, title = {Mechanical Ventilation in Children on Venovenous ECMO}, volume = {65}, number = {3}, pages = {271--280}, year = {2020}, doi = {10.4187/respcare.07214}, publisher = {Respiratory Care}, abstract = {BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used when mechanical ventilation can no longer support oxygenation or ventilation, or if the risk of ventilator-induced lung injury is considered excessive. The optimum mechanical ventilation strategy once on ECMO is unknown. We sought to describe the practice of mechanical ventilation in children on VV-ECMO and to determine whether mechanical ventilation practices are associated with clinical outcomes.METHODS: We conducted a multicenter retrospective cohort study in 10 pediatric academic centers in the United States. Children age 14 d through 18 y on VV-ECMO from 2011 to 2016 were included. Exclusion criteria were preexisting chronic respiratory failure, primary diagnosis of asthma, cyanotic heart disease, or ECMO as a bridge to lung transplant.RESULTS: Conventional mechanical ventilation was used in about 75\% of children on VV-ECMO; the remaining subjects were managed with a variety of approaches. With the exception of PEEP, there was large variation in ventilator settings. Ventilator mode and pressure settings were not associated with survival. Mean ventilator FIO2 on days 1{\textendash}3 was higher in nonsurvivors than in survivors (0.5 vs 0.4, P = .009). In univariate analysis, other risk factors for mortality were female gender, higher Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS), diagnosis of cancer or stem cell transplant, and number of days intubated prior to initiation of ECMO (all P \< .05). In multivariate analysis, ventilator FIO2 was significantly associated with mortality (odds ratio 1.38 for each 0.1 increase in FIO2, 95\% CI 1.09-1.75). Mortality was higher in subjects on high ventilator FIO2 (>= 0.5) compared to low ventilator FIO2 (\> 0.5) (46\% vs 22\%, P = .001).CONCLUSIONS: Ventilator mode and some settings vary in practice. The only ventilator setting associated with mortality was FIO2, even after adjustment for disease severity. Ventilator FIO2 is a modifiable setting that may contribute to mortality in children on VV-ECMO.}, issn = {0020-1324}, URL = {https://rc.rcjournal.com/content/65/3/271}, eprint = {https://rc.rcjournal.com/content/65/3/271.full.pdf}, journal = {Respiratory Care} }