Original

Intensive Care Medicine

, Volume 39, Issue 5, pp 847-856

Open Access This content is freely available online to anyone, anywhere at any time.

Lower tidal volume strategy (≈3 ml/kg) combined with extracorporeal CO2 removal versus ‘conventional’ protective ventilation (6 ml/kg) in severe ARDS

The prospective randomized Xtravent-study
  • Thomas BeinAffiliated withDepartment of Anesthesia and Operative Intensive Care, Regensburg University HospitalDepartment of Anesthesia and Critical Care, Regensburg University Hospital Email author 
  • , Steffen Weber-CarstensAffiliated withDepartment of Anesthesia and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin
  • , Anton GoldmannAffiliated withDepartment of Anesthesia and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin
  • , Thomas MüllerAffiliated withDepartment of Internal Medicine II, Regensburg University Hospital
  • , Thomas StaudingerAffiliated withIntensive Care Unit, Department of Internal Medicine I, Vienna General Hospital, Medical University of Vienna
  • , Jörg BrederlauAffiliated withDepartment of Intensive Care Medicine, HELIOS Klinikum Berlin-Buch
  • , Ralf MuellenbachAffiliated withDepartment of Anaesthesia and Critical Care, University of Würzburg
  • , Rolf DembinskiAffiliated withDepartment of Intensive Care, University Hospital Aachen, RWTH Aachen University
  • , Bernhard M. GrafAffiliated withDepartment of Anesthesia and Operative Intensive Care, Regensburg University Hospital
    • , Marlene WewalkaAffiliated withIntensive Care Unit, Division of Gastroenterology, Department of Internal Medicine III, Vienna General Hospital, Medical University of Vienna
    • , Alois PhilippAffiliated withDepartment of Cardiothoracic Surgery, Regensburg University Hospital
    • , Klaus-Dieter WerneckeAffiliated withDepartment of Anesthesia and Operative Intensive Care, Regensburg University HospitalDepartment of Anesthesia and Operative Intensive Care Medicine, Charité Universitätsmedizin BerlinSOSTANA GmbH, Biometric Statistical Analyses
    • , Matthias LubnowAffiliated withDepartment of Internal Medicine II, Regensburg University Hospital
    • , Arthur S. SlutskyAffiliated withDepartment of Anesthesia and Operative Intensive Care, Regensburg University HospitalInterdepartmental Division of Critical Care Medicine, Department of Medicine, Keenan Research Center at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, University of Toronto

Abstract

Background

Acute respiratory distress syndrome is characterized by damage to the lung caused by various insults, including ventilation itself, and tidal hyperinflation can lead to ventilator induced lung injury (VILI). We investigated the effects of a low tidal volume (V T) strategy (V T ≈ 3 ml/kg/predicted body weight [PBW]) using pumpless extracorporeal lung assist in established ARDS.

Methods

Seventy-nine patients were enrolled after a ‘stabilization period’ (24 h with optimized therapy and high PEEP). They were randomly assigned to receive a low V T ventilation (≈3 ml/kg) combined with extracorporeal CO2 elimination, or to a ARDSNet strategy (≈6 ml/kg) without the extracorporeal device. The primary outcome was the 28-days and 60-days ventilator-free days (VFD). Secondary outcome parameters were respiratory mechanics, gas exchange, analgesic/sedation use, complications and hospital mortality.

Results

Ventilation with very low V T’s was easy to implement with extracorporeal CO2-removal. VFD’s within 60 days were not different between the study group (33.2 ± 20) and the control group (29.2 ± 21, p = 0.469), but in more hypoxemic patients (PaO2/FIO2 ≤150) a post hoc analysis demonstrated significant improved VFD-60 in study patients (40.9 ± 12.8) compared to control (28.2 ± 16.4, p = 0.033). The mortality rate was low (16.5 %) and did not differ between groups.

Conclusions

The use of very low V T combined with extracorporeal CO2 removal has the potential to further reduce VILI compared with a ‘normal’ lung protective management. Whether this strategy will improve survival in ARDS patients remains to be determined (Clinical trials NCT 00538928).

Keywords

Lung protective ventilation Pumpless extracorporeal lung support Carbon dioxide removal Acute respiratory distress syndrome Ultraprotective ventilation