Don’t Drive Blind: Driving Pressure to Optimize Ventilator Management in ECMO

INTRODUCTION: Driving pressure (DP) while on ECMO has been studied in acute respiratory distress syndrome (ARDS) but no studies exist in those on ECMO without ARDS. We aimed to study association of mortality with DP in all patients on ECMO and compare change in DP before and after initiation of ECMO. METHODS: Consecutive patients placed on ECMO either veno-arterial ECMO or veno-venous ECMO between August 2010 and February 2017 were reviewed. The outcomes were compared based on DP before and after ECMO initiation. RESULTS: A total of 192 patients were included: 68 (35%) had ARDS while 124 (65%) did not. There were 70 individuals for whom DP was available, 33 (47%) had a decrease in DP, whereas 32 (46%) had an increase in DP and 5 (7%) had no change in DP after ECMO initiation. Those with an increase in DP had a higher initial PEEP (14 vs 9 cm H(2)O, p < 0.001) and a higher PEEP decrease after ECMO (6.4 cm H(2)O vs by 2.5 cm H(2)O, p < 0.001). Those with an increase in DP had a significantly longer stay on ECMO than those without (p = 0.022). On multivariable analysis, higher DP 24 h after ECMO initiation was associated with an increase in 30-day mortality (OR 1.15, 75% CI 1.07–1.24, p ≤ 0.001). CONCLUSION: A significant proportion of patients experienced an increase in driving pressure and decrease in compliance after initiation of ECMO. Higher driving pressure after initiation of ECMO is associated with increased adjusted 30-day mortality. Individualized ventilator strategies are needed to reduce mechanical stress while on ECMO.