Goursaud Suzanne, Valette Xavier, Dupeyrat Julien, Daubin Cédric, du Cheyron Damien
CHU de Caen Normandie, Service de Réanimation Médicale, Av côte de Nacre, 14000, Caen, France.
Normandie Univ, UNICAEN, INSERM, U1237, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, 14000, Caen, France.
Ann Intensive Care. 2021 Jan 7;11(1):3. doi: 10.1186/s13613-020-00784-3.
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 CO removal (ECCOR) might allow ultraprotective ventilation with lower tidal volume (V) and plateau pressure (P). This study investigated whether ECCOR therapy could affect RV function.
This was a quasi-experimental prospective observational pilot study performed in a French medical ICU. Patients with moderate-to-severe ARDS with PaO/FiO ratio between 80 and 150 mmHg were enrolled. An ultraprotective ventilation strategy was used with V at 4 mL/kg of predicted body weight during the 24 h following the start of a low-flow ECCOR device. RV function was assessed by transthoracic echocardiography (TTE) during the study protocol.
The efficacy of ECCOR 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.
Low-flow ECCOR 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 PaCO.
右心室（RV）衰竭是中重度急性呼吸窘迫综合征（ARDS）的常见并发症。高碳酸血症性酸中毒和机械通气引起的过度扩张会加重RV衰竭。静脉-静脉体外二氧化碳清除（ECCOR）可能允许采用低潮气量（V）和平台压（P）的超保护性通气。本研究调查了ECCOR治疗是否会影响RV功能。
这是一项在法国一家医疗重症监护病房进行的准实验性前瞻性观察性试点研究。纳入了中度至重度ARDS且动脉血氧分压/吸入氧分数值（PaO/FiO）在80至150 mmHg之间的患者。在低流量ECCOR设备启动后的24小时内，采用超保护性通气策略，V设定为预测体重的4 mL/kg。在研究方案期间，通过经胸超声心动图（TTE）评估RV功能。
ECCOR的有效性使纳入的所有18例患者都能采用超保护性策略。我们观察到RV收缩功能参数有显著改善。与基线相比，超保护性通气下三尖瓣环平面收缩期位移（TAPSE）显著增加（从22.8 mm增至25.4 mm；p < 0.05）。在1天的方案后，收缩期位移速度（S'波）也增加了（从13.8 m/s增至15.1 m/s；p < 0.05）。在超保护性通气设置下，观察到主动脉速度时间积分（VTIAo）有显著改善（p = 0.05）。收缩期肺动脉压（sPAP）和RV前负荷值无显著差异。
低流量ECCOR有助于采用超保护性通气策略，可改善中重度ARDS患者的RV功能。RV收缩力的改善似乎主要是由于超保护性通气使胸内压降低，而非动脉血二氧化碳分压（PaCO）的降低。
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