PT  - JOURNAL ARTICLE
AU  - Matthew L Friedman
AU  - Ryan P Barbaro
AU  - Melania M Bembea
AU  - Brian C Bridges
AU  - Ranjit S Chima
AU  - Todd J Kilbaugh
AU  - Poornima Pandiyan
AU  - Renee M Potera
AU  - Elizabeth A Rosner
AU  - Hitesh S Sandhu
AU  - James E Slaven
AU  - Keiko M Tarquinio
AU  - Ira M Cheifetz
TI  - Mechanical Ventilation in Children on Venovenous ECMO
AID  - 10.4187/respcare.07214
DP  - 2020 Mar 01
TA  - Respiratory Care
PG  - 271--280
VI  - 65
IP  - 3
4099  - http://rc.rcjournal.com/content/65/3/271.short
4100  - http://rc.rcjournal.com/content/65/3/271.full
AB  - 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 1–3 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.