Ultraprotective ventilation allowed by extracorporeal CO2 removal improves the right ventricular function in acute respiratory distress syndrome patients: a quasi-experimental pilot study

Suzanne Goursaud; Xavier Valette; Julien Dupeyrat; Cédric Daubin; Damien du Cheyron

doi:10.1186/s13613-020-00784-3

Ultraprotective ventilation allowed by extracorporeal CO₂ removal improves the right ventricular function in acute respiratory distress syndrome patients: a quasi-experimental pilot study

Ann Intensive Care. 2021 Jan 7;11(1):3. doi: 10.1186/s13613-020-00784-3.

Authors

Suzanne Goursaud^{1

2}, Xavier Valette³, Julien Dupeyrat³, Cédric Daubin³, Damien du Cheyron³

Affiliations

¹ CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France. goursaud-s@chu-caen.fr.
² Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000, Caen, France. goursaud-s@chu-caen.fr.
³ CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France.

Abstract

Background: Right ventricular (RV) failure is a common complication in moderate-to-severe acute respiratory distress syndrome (ARDS). RV failure is exacerbated by hypercapnic acidosis and overdistension induced by mechanical ventilation. Veno-venous extracorporeal CO₂ removal (ECCO₂R) might allow ultraprotective ventilation with lower tidal volume (V_T) and plateau pressure (P_plat). This study investigated whether ECCO₂R therapy could affect RV function.

Methods: This was a quasi-experimental prospective observational pilot study performed in a French medical ICU. Patients with moderate-to-severe ARDS with PaO₂/FiO₂ ratio between 80 and 150 mmHg were enrolled. An ultraprotective ventilation strategy was used with V_T at 4 mL/kg of predicted body weight during the 24 h following the start of a low-flow ECCO₂R device. RV function was assessed by transthoracic echocardiography (TTE) during the study protocol.

Results: The efficacy of ECCO₂R facilitated an ultraprotective strategy in all 18 patients included. We observed a significant improvement in RV systolic function parameters. Tricuspid annular plane systolic excursion (TAPSE) increased significantly under ultraprotective ventilation compared to baseline (from 22.8 to 25.4 mm; p < 0.05). Systolic excursion velocity (S' wave) also increased after the 1-day protocol (from 13.8 m/s to 15.1 m/s; p < 0.05). A significant improvement in the aortic velocity time integral (VTIAo) under ultraprotective ventilation settings was observed (p = 0.05). There were no significant differences in the values of systolic pulmonary arterial pressure (sPAP) and RV preload.

Conclusion: Low-flow ECCO₂R facilitates an ultraprotective ventilation strategy thatwould improve RV function in moderate-to-severe ARDS patients. Improvement in RV contractility appears to be mainly due to a decrease in intrathoracic pressure allowed by ultraprotective ventilation, rather than a reduction of PaCO₂.

Keywords: Acute respiratory distress syndrome; Critical care echocardiography; Extracorporeal CO2 removal; Protective mechanical ventilation; Right ventricular dysfunction.