The association of modifiable mechanical ventilation settings, blood gas changes and survival on extracorporeal membrane oxygenation for cardiac arrest

Joseph E. Tonna; Craig H. Selzman; Jason A. Bartos; Angela P. Presson; Zhining Ou; Yeonjung Jo; Lance B. Becker; Scott T. Youngquist; Ravi R. Thiagarajan; M. Austin Johnson; Sung Min Cho; Peter Rycus; Heather T. Keenan

doi:10.1016/j.resuscitation.2022.03.016

The association of modifiable mechanical ventilation settings, blood gas changes and survival on extracorporeal membrane oxygenation for cardiac arrest

Joseph E. Tonna, Craig H. Selzman, Jason A. Bartos, Angela P. Presson, Zhining Ou, Yeonjung Jo, Lance B. Becker, Scott T. Youngquist, Ravi R. Thiagarajan, M. Austin Johnson, Sung Min Cho, Peter Rycus, Heather T. Keenan

Medicine - Cardiology Division

Research output: Contribution to journal › Article › peer-review

7 Scopus citations

Abstract

RESEARCH QUESTION: Given the relative independence of ventilator settings from gas exchange and plasticity of blood gas values during extracorporeal cardiopulmonary resuscitation (ECPR), do mechanical ventilation parameters and blood gas values influence survival?

METHODS: Observational cohort study of 7488 adult patients with ECPR from the Extracorporeal Life Support Organization (ELSO) Registry. We performed case-mix adjustment for severity of illness and patient type using generalized estimating equation logistic regression to determine factors associated with hospital survival accounting for clustering by center, standardizing variables by 1 standard deviation (SD) of their values. We examined non-linear relationships between ventilatory and blood gas values with hospital survival.

RESULTS: Hospital survival was decreased with higher PaO 2 on ECMO (OR 0.69, per 1SD increase [95% CI 0.64, 0.74]; p < 0.001) and with any relative changes in PaCO 2 (pre-arrest to on-ECMO) in a non-linear fashion. Survival was worsened with any peak inspiratory pressure >20 cmH 20 (OR 0.69, per 1SD [0.64, 0.75]; p < 0.001) and above 40% fraction of inspired oxygen (OR 0.75, per 1SD [0.69, 0.82]; p < 0.001), and with higher dynamic driving pressure (OR 0.72, per 1 SD increase [0.65, 0.79]; <0.001). Ventilation settings and blood gas values varied widely across hospitals, but were not associated with annual hospital ECPR case volume.

CONCLUSION: Lower ventilatory pressures, avoidance of hyperoxia, and relatively unchanged CO 2 (pre- to on-ECMO) were all associated with survival in patients after ECPR, yet varied across hospitals. Our findings represent potential targets for prospective trials for this rapidly growing therapy to test if these associations have causality.

Original language	English (US)
Pages (from-to)	53-61
Number of pages	9
Journal	Resuscitation
Volume	174
DOIs	https://doi.org/10.1016/j.resuscitation.2022.03.016
State	Published - May 2022

Bibliographical note

Funding Information:
Dr. Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23 HL141596). This study was also supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR002538 (formerly 5UL1TR001067-05, 8UL1TR000105 and UL1RR025764). None of the funding sources were involved in the design or conduct of the study, collection, management, analysis or interpretation of the data, or preparation, review or approval of the manuscript.

Funding Information:
JT, JB, AP, ZO, YJ, and HTK conceived the work. JT, AP, ZO, YJ, PR, and HK conducted the project. JT, AP, ZO, YJ, PR and HK conducted the data acquisition and analysis. JT, AP, ZO, YJ and HK drafted the manuscript. All authors revised the article for important intellectual content, had approved the final manuscript for publication. JT had full access to the project data and takes responsibility for the data integrity, accuracy, and integrity of the submission as a whole. Dr. Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23 HL141596). This study was also supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR002538 (formerly 5UL1TR001067-05, 8UL1TR000105 and UL1RR025764). None of the funding sources were involved in the design or conduct of the study, collection, management, analysis or interpretation of the data, or preparation, review or approval of the manuscript. This analysis was approved by the ELSO Scientific Oversight Committee and by the Institutional Review Board at the University of Utah #91962

Publisher Copyright:
© 2022 Elsevier B.V.

Keywords

Blood gas changes
Extracorporeal cardiopulmonary resuscitation
Intensive care
Management
Mechanical ventilation
Post-cannulation care
Ventilation
Ventilatory management

PubMed: MeSH publication types

Journal Article
Observational Study
Research Support, N.I.H., Extramural

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10.1016/j.resuscitation.2022.03.016

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Tonna, J. E., Selzman, C. H., Bartos, J. A., Presson, A. P., Ou, Z., Jo, Y., Becker, L. B., Youngquist, S. T., Thiagarajan, R. R., Austin Johnson, M., Cho, S. M., Rycus, P., & Keenan, H. T. (2022). The association of modifiable mechanical ventilation settings, blood gas changes and survival on extracorporeal membrane oxygenation for cardiac arrest. Resuscitation, 174, 53-61. https://doi.org/10.1016/j.resuscitation.2022.03.016

Tonna, JE, Selzman, CH, Bartos, JA, Presson, AP, Ou, Z, Jo, Y, Becker, LB, Youngquist, ST, Thiagarajan, RR, Austin Johnson, M, Cho, SM, Rycus, P & Keenan, HT 2022, 'The association of modifiable mechanical ventilation settings, blood gas changes and survival on extracorporeal membrane oxygenation for cardiac arrest', Resuscitation, vol. 174, pp. 53-61. https://doi.org/10.1016/j.resuscitation.2022.03.016

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title = "The association of modifiable mechanical ventilation settings, blood gas changes and survival on extracorporeal membrane oxygenation for cardiac arrest",

abstract = "RESEARCH QUESTION: Given the relative independence of ventilator settings from gas exchange and plasticity of blood gas values during extracorporeal cardiopulmonary resuscitation (ECPR), do mechanical ventilation parameters and blood gas values influence survival?METHODS: Observational cohort study of 7488 adult patients with ECPR from the Extracorporeal Life Support Organization (ELSO) Registry. We performed case-mix adjustment for severity of illness and patient type using generalized estimating equation logistic regression to determine factors associated with hospital survival accounting for clustering by center, standardizing variables by 1 standard deviation (SD) of their values. We examined non-linear relationships between ventilatory and blood gas values with hospital survival.RESULTS: Hospital survival was decreased with higher PaO 2 on ECMO (OR 0.69, per 1SD increase [95% CI 0.64, 0.74]; p < 0.001) and with any relative changes in PaCO 2 (pre-arrest to on-ECMO) in a non-linear fashion. Survival was worsened with any peak inspiratory pressure >20 cmH 20 (OR 0.69, per 1SD [0.64, 0.75]; p < 0.001) and above 40% fraction of inspired oxygen (OR 0.75, per 1SD [0.69, 0.82]; p < 0.001), and with higher dynamic driving pressure (OR 0.72, per 1 SD increase [0.65, 0.79]; <0.001). Ventilation settings and blood gas values varied widely across hospitals, but were not associated with annual hospital ECPR case volume. CONCLUSION: Lower ventilatory pressures, avoidance of hyperoxia, and relatively unchanged CO 2 (pre- to on-ECMO) were all associated with survival in patients after ECPR, yet varied across hospitals. Our findings represent potential targets for prospective trials for this rapidly growing therapy to test if these associations have causality. ",

keywords = "Blood gas changes, Extracorporeal cardiopulmonary resuscitation, Intensive care, Management, Mechanical ventilation, Post-cannulation care, Ventilation, Ventilatory management",

author = "Tonna, {Joseph E.} and Selzman, {Craig H.} and Bartos, {Jason A.} and Presson, {Angela P.} and Zhining Ou and Yeonjung Jo and Becker, {Lance B.} and Youngquist, {Scott T.} and Thiagarajan, {Ravi R.} and {Austin Johnson}, M. and Cho, {Sung Min} and Peter Rycus and Keenan, {Heather T.}",

note = "Funding Information: Dr. Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23 HL141596). This study was also supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR002538 (formerly 5UL1TR001067-05, 8UL1TR000105 and UL1RR025764). None of the funding sources were involved in the design or conduct of the study, collection, management, analysis or interpretation of the data, or preparation, review or approval of the manuscript. Funding Information: JT, JB, AP, ZO, YJ, and HTK conceived the work. JT, AP, ZO, YJ, PR, and HK conducted the project. JT, AP, ZO, YJ, PR and HK conducted the data acquisition and analysis. JT, AP, ZO, YJ and HK drafted the manuscript. All authors revised the article for important intellectual content, had approved the final manuscript for publication. JT had full access to the project data and takes responsibility for the data integrity, accuracy, and integrity of the submission as a whole. Dr. Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23 HL141596). This study was also supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR002538 (formerly 5UL1TR001067-05, 8UL1TR000105 and UL1RR025764). None of the funding sources were involved in the design or conduct of the study, collection, management, analysis or interpretation of the data, or preparation, review or approval of the manuscript. This analysis was approved by the ELSO Scientific Oversight Committee and by the Institutional Review Board at the University of Utah #91962 Publisher Copyright: {\textcopyright} 2022 Elsevier B.V.",

year = "2022",

month = may,

doi = "10.1016/j.resuscitation.2022.03.016",

language = "English (US)",

volume = "174",

pages = "53--61",

journal = "Resuscitation",

issn = "0300-9572",

publisher = "Elsevier Ireland Ltd",

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TY - JOUR

T1 - The association of modifiable mechanical ventilation settings, blood gas changes and survival on extracorporeal membrane oxygenation for cardiac arrest

AU - Tonna, Joseph E.

AU - Selzman, Craig H.

AU - Bartos, Jason A.

AU - Presson, Angela P.

AU - Ou, Zhining

AU - Jo, Yeonjung

AU - Becker, Lance B.

AU - Youngquist, Scott T.

AU - Thiagarajan, Ravi R.

AU - Austin Johnson, M.

AU - Cho, Sung Min

AU - Rycus, Peter

AU - Keenan, Heather T.

N1 - Funding Information: Dr. Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23 HL141596). This study was also supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR002538 (formerly 5UL1TR001067-05, 8UL1TR000105 and UL1RR025764). None of the funding sources were involved in the design or conduct of the study, collection, management, analysis or interpretation of the data, or preparation, review or approval of the manuscript. Funding Information: JT, JB, AP, ZO, YJ, and HTK conceived the work. JT, AP, ZO, YJ, PR, and HK conducted the project. JT, AP, ZO, YJ, PR and HK conducted the data acquisition and analysis. JT, AP, ZO, YJ and HK drafted the manuscript. All authors revised the article for important intellectual content, had approved the final manuscript for publication. JT had full access to the project data and takes responsibility for the data integrity, accuracy, and integrity of the submission as a whole. Dr. Tonna is supported by a Career Development Award from the National Institutes of Health/National Heart, Lung, And Blood Institute (K23 HL141596). This study was also supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant UL1TR002538 (formerly 5UL1TR001067-05, 8UL1TR000105 and UL1RR025764). None of the funding sources were involved in the design or conduct of the study, collection, management, analysis or interpretation of the data, or preparation, review or approval of the manuscript. This analysis was approved by the ELSO Scientific Oversight Committee and by the Institutional Review Board at the University of Utah #91962 Publisher Copyright: © 2022 Elsevier B.V.

PY - 2022/5

Y1 - 2022/5

N2 - RESEARCH QUESTION: Given the relative independence of ventilator settings from gas exchange and plasticity of blood gas values during extracorporeal cardiopulmonary resuscitation (ECPR), do mechanical ventilation parameters and blood gas values influence survival?METHODS: Observational cohort study of 7488 adult patients with ECPR from the Extracorporeal Life Support Organization (ELSO) Registry. We performed case-mix adjustment for severity of illness and patient type using generalized estimating equation logistic regression to determine factors associated with hospital survival accounting for clustering by center, standardizing variables by 1 standard deviation (SD) of their values. We examined non-linear relationships between ventilatory and blood gas values with hospital survival.RESULTS: Hospital survival was decreased with higher PaO 2 on ECMO (OR 0.69, per 1SD increase [95% CI 0.64, 0.74]; p < 0.001) and with any relative changes in PaCO 2 (pre-arrest to on-ECMO) in a non-linear fashion. Survival was worsened with any peak inspiratory pressure >20 cmH 20 (OR 0.69, per 1SD [0.64, 0.75]; p < 0.001) and above 40% fraction of inspired oxygen (OR 0.75, per 1SD [0.69, 0.82]; p < 0.001), and with higher dynamic driving pressure (OR 0.72, per 1 SD increase [0.65, 0.79]; <0.001). Ventilation settings and blood gas values varied widely across hospitals, but were not associated with annual hospital ECPR case volume. CONCLUSION: Lower ventilatory pressures, avoidance of hyperoxia, and relatively unchanged CO 2 (pre- to on-ECMO) were all associated with survival in patients after ECPR, yet varied across hospitals. Our findings represent potential targets for prospective trials for this rapidly growing therapy to test if these associations have causality.

AB - RESEARCH QUESTION: Given the relative independence of ventilator settings from gas exchange and plasticity of blood gas values during extracorporeal cardiopulmonary resuscitation (ECPR), do mechanical ventilation parameters and blood gas values influence survival?METHODS: Observational cohort study of 7488 adult patients with ECPR from the Extracorporeal Life Support Organization (ELSO) Registry. We performed case-mix adjustment for severity of illness and patient type using generalized estimating equation logistic regression to determine factors associated with hospital survival accounting for clustering by center, standardizing variables by 1 standard deviation (SD) of their values. We examined non-linear relationships between ventilatory and blood gas values with hospital survival.RESULTS: Hospital survival was decreased with higher PaO 2 on ECMO (OR 0.69, per 1SD increase [95% CI 0.64, 0.74]; p < 0.001) and with any relative changes in PaCO 2 (pre-arrest to on-ECMO) in a non-linear fashion. Survival was worsened with any peak inspiratory pressure >20 cmH 20 (OR 0.69, per 1SD [0.64, 0.75]; p < 0.001) and above 40% fraction of inspired oxygen (OR 0.75, per 1SD [0.69, 0.82]; p < 0.001), and with higher dynamic driving pressure (OR 0.72, per 1 SD increase [0.65, 0.79]; <0.001). Ventilation settings and blood gas values varied widely across hospitals, but were not associated with annual hospital ECPR case volume. CONCLUSION: Lower ventilatory pressures, avoidance of hyperoxia, and relatively unchanged CO 2 (pre- to on-ECMO) were all associated with survival in patients after ECPR, yet varied across hospitals. Our findings represent potential targets for prospective trials for this rapidly growing therapy to test if these associations have causality.

KW - Blood gas changes

KW - Extracorporeal cardiopulmonary resuscitation

KW - Intensive care

KW - Management

KW - Mechanical ventilation

KW - Post-cannulation care

KW - Ventilation

KW - Ventilatory management

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SN - 0300-9572

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JO - Resuscitation

JF - Resuscitation

ER -

The association of modifiable mechanical ventilation settings, blood gas changes and survival on extracorporeal membrane oxygenation for cardiac arrest

Abstract

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Keywords

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