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• W3143360520 abstract "We have read with interest the article by Bullen et al1Bullen E.C. Teijeiro-Paradis R. Fan E. How I select which patients with ARDS should be treated with venovenous extracorporeal membrane oxygenation.Chest. 2020; 158: 1036-1045Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar in the September 2020 issue of CHEST. The authors provide the example of a patient with severe ARDS and respiratory acidosis leading to veno-venous extracorporeal membrane oxygenation (VV-ECMO) and propose a detailed algorithm to select patients requiring VV-ECMO. In this algorithm, one important step is missing. The optimization of lung-protective ventilation should include minimization of the dead space. The total dead space includes the instrumental dead space (comprising the heat and moisture exchanger, catheter mount, several connectors, and the endotracheal tube), in addition to the anatomical dead space and alveolar dead space (Fig 1). The dead space reduces CO2 removal, and this effect is particularly relevant when low or very low tidal volumes (TVs) (≤ 6 mL/kg predicted body weight [PBW]) are set in association with a high or very high respiratory rate (RR) (≥ 25 breaths/min),2Lellouche F. Delorme M. Brochard L. Impact of respiratory rate and dead space in the current era of lung protective mechanical ventilation.Chest. 2020; 158: 45-47Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar which is usually the case in patients with severe ARDS who are potential candidates for ECMO. The impact of instrumental dead space has been shown previously when moderately reduced TV and moderately increased RR were used. In the study by Prat et al,3Prat G. Renault A. Tonnelier J.M. et al.Influence of the humidification device during acute respiratory distress syndrome.Intensive Care Med. 2003; 29: 2211-2215Crossref PubMed Scopus (42) Google Scholar the Paco2 went from 80.3 mm Hg to 63.6 mm Hg after reducing the instrumental dead space from 120 mL to 0 mL in 10 patients with ARDS. The mean TV was 6.9 mL/kg, and the mean RR was 20 breaths/min. More recently, Richard et al4Richard J.C. Marque S. Gros A. et al.REVA Research NetworkFeasibility and safety of ultra-low tidal volume ventilation without extracorporeal circulation in moderately severe and severe ARDS patients.Intensive Care Med. 2019; 45: 1590-1598Crossref PubMed Scopus (14) Google Scholar found that 88% of the patients had a TV < 5.25 mL/kg PBW and two-thirds of the patients with ARDS could receive ultraprotective ventilation (mean TV < 4.2 mL/kg PBW) without extracorporeal CO2 removal when mechanical ventilation management was optimized. Optimization comprised a reduction of the dead space (by replacing the heat and moisture exchanger by a heated humidifier and by removing useless connectors such as the catheter mount) and with high RR. The maximal reduction of the dead space is now a recommendation for managing patients with ARDS.5Papazian L. Aubron C. Brochard L. et al.Formal guidelines: management of acute respiratory distress syndrome.Ann Intensive Care. 2019; 9: 69Crossref PubMed Scopus (186) Google Scholar However, it would be acceptable to use ECMO or extracorporeal CO2 removal if Paco2 remained too high (after minimizing the dead space) to further decrease TVs and implement ultraprotective ventilation. It would not be acceptable to call for ECMO, however, if the step of dead space minimization is not achieved. Ventilator circuit change is far less invasive compared with putting in an ECMO and is frequently very effective. How I Select Which Patients With ARDS Should Be Treated With Venovenous Extracorporeal Membrane OxygenationCHESTVol. 158Issue 3PreviewARDS is a lethal form of acute respiratory failure, and because no specific treatments exist, supportive care remains the primary management strategy in these patients. Extracorporeal membrane oxygenation (ECMO) has emerged as an intervention in patients with severe ARDS to facilitate gas exchange and the delivery of more lung protective ventilation. Over the past 20 years, improvements in ECMO technology have increased its safety and transportability, making it far more available to this patient population globally. Full-Text PDF ResponseCHESTVol. 159Issue 4PreviewWe thank Dr Lellouche for his letter regarding the optimization of dead space ventilation by reducing instrumental dead space in patients with severe ARDS. As mentioned, dead space ventilation is composed of physiological, anatomical, and instrumental components. Physiological dead space can be optimized by reducing alveolar overdistension by incorporating lung-protective ventilation. Instrumental and anatomical dead space, conversely, requires modification of the ventilator circuit or patient-ventilator interface. Full-Text PDF" @default.
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• W3143360520 date "2021-04-01" @default.
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• W3143360520 title "Decrease Dead Space Prior to Calling the ECMO!" @default.
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• W3143360520 doi "https://doi.org/10.1016/j.chest.2020.11.067" @default.
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