Medizinische Klinik, Intensivmedizin und Notfallmedizin
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Med Klin Intensivmed Notfmed · Feb 2018
ReviewIndications for extracorporeal support: why do we need the results of the EOLIA trial?
Acute respiratory distress syndrome (ARDS) is a severe lung disease, with an associated mortality rate exceeding 60% for the most severe forms of the disease. In these situations, establishing an extracorporeal circuit, combining a centrifugal pump and a membrane oxygenator (extra-corporeal membrane oxygenation, ECMO), can ensure total pulmonary assistance and allow the lungs to rest under ultraprotective mechanical ventilation. Unfortunately, former trials of ECMO in ARDS were negative or highly criticized due to many technical and methodological shortcomings. ⋯ Therefore, the international multicenter randomized EOLIA (ECMO to rescue Lung Injury in severe ARDS) trial was designed to test the benefit of systematic and early installation of the latest-generation ECMO circuits in patients with very severe ARDS. Patients randomized to the control group were managed with tight control of mechanical ventilation and recourse to paralyzing agents and prone positioning, while an ethical crossover option to ECMO was permitted only if refractory hypoxemia (SaO2 < 80%) lasted for > 6 h despite all possible conventional emergency interventions. The primary endpoint of the study was the 60-day mortality rate, with an expected 20% absolute mortality reduction with ECMO.
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Esophageal manometry has traditionally been utilized for respiratory physiology research, but clinicians have recently found numerous applications within the intensive care unit. Esophageal pressure (PEs) is a surrogate for pleural pressures (PPl), and the difference between airway pressure (PAO) and PEs provides a good estimate for the pressure across the lung also known as the transpulmonary pressure (PL). Differentiating the effects of mechanical ventilation and spontaneous breathing on the respiratory system, chest wall, and across the lung allows for improved personalization in clinical decision making. ⋯ Intrinsic PEEP (auto-PEEP) may be monitored using esophageal manometry, which may also improve patient comfort and synchrony with the ventilator. Finally, during weaning, PEs may be used to better predict weaning success and allow for rapid intervention during failure. Improved consistency in definition and terminology and further outcomes research is needed to encourage more widespread adoption; however, with clear clinical benefit and increased ease of use, it appears time to reintroduce basic physiology into personalized ventilator management in the intensive care unit.