Pulmonary Disorders I

ARDS or more specifically with Pao2/Fio2 ratios less than 80 mm Hg and/or in patients with elevated

plateau pressures despite optimizing PEEP, neuromuscular blocking agents (NMBAs), and prone

ESICM clinical practice guidelines recommend ECMO use in severe ARDS (as defined in EOLIA

trial eligibility criteria) at an established ECMO center (strong recommendation; moderate level

(ATS) guidelines suggest the use of veno-venous ECMO (VV ECMO) in patients early in their

course (less than 7 days) with reversible etiologies of respiratory failure and very severe hypoxemia

(Paco2/Fio2 ratio less than 80 mm Hg) or hypercapnia (pH less than 7.25 with Paco2 60 mm Hg) after

Concomitant VV ECMO and prone positioning

A meta-analysis (n=13 studies including only 1 randomized clinical trial) evaluated the clinical

impact of prone positioning and VV ECMO in ARDS compared with VV ECMO alone

ii.

Pooled data showed combination VV ECMO and prone positioning 28-day survival was

significantly improved (n=10 studies; RR 1.31; 95% CI, 1.21–1.41). Also, combination therapy

was also associated with significantly improved ICU and in-hospital survival as well as overall

60- and 90-day survival.

iii.

A priori subgroup analyses found improved 28-day survival with concomitant prone positioning

and VV ECMO in both patient cohorts with COVID-19 ARDS patients (n=6 studies; RR 1.32;

95% CI, 1.15–1.50) and ARDS patients without COVID-19 (n=4 studies; RR 1.30; 95% CI,

1.19–1.43).

iv.

Pooled data also showed significant improvements in ventilator-free days at day 28 (n=9 studies;

RR −1.29; 95% CI, −2.39 to −0.19) with prone positioning and VV ECMO over ECMO alone

in ARDS patients

No major complications were reported with either study group.

Fluid management

The FACTT trial compared 2 optimal fluid management strategies (conservative (CVP less than

4 mm Hg) and liberal (CVP 10–14 mm Hg) in patients with ARDS and hemodynamic stability

Diuretics were withheld in patients with shock but were administered according to study protocol

once patients had established hemodynamic stability (discontinuation of vasopressors or MAP

greater than 60 mm Hg). Although 60-day mortality did not differ (p=0.30), the conservative

compared with the liberal strategy was associated with increased ventilator-free days (14.6 ± 0.5 vs.

12.1 ± 0.5, p<0.001) and ICU-free days (28 days) (13.4 ± 0.4 vs. 11.2 ± 0.4, p<0.001).

Fluid strategies were compared (conservative, liberal, and simplified conservative) in a retrospective

Lite protocol provides fluid management recommendations pertaining to the administration of

furosemide or fluids as well as monitoring without intervention-based CVP, MAP, urinary output,

and pulmonary artery occlusion pressure (optional) (Table 3). No significant differences were found

between the FACTT Lite and the FACTT conservative strategies for ventilator-free days (14.9 vs.

14.6, respectively; p=0.61), ICU-free days (14.4 vs. 13.4, respectively; p=0.054), or death at 60 days

(22% vs. 25%, respectively; p=0.15). Conversely, the FACTT Lite approach had improved outcomes

(ventilator-free, ICU-days, and 60-day mortality) compared with the FACTT liberal approach.

A meta-analysis evaluated the safety and efficacy of conservative versus liberal fluid strategies in

mortality were found between study groups in the ARDS subgroup (n=5 studies; RR 0.91; 95% CI,

0.77–1.07) or the mixed ARDS and sepsis subgroup (n=2 studies; RR 0.95; 95% CI, 0.80–1.14).