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Intensive Care Medicine
Published in: Intensive Care Medicine 3/2012

01-03-2012 | Original

ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure

Authors: Salvatore Grasso, Pierpaolo Terragni, Alberto Birocco, Rosario Urbino, Lorenzo Del Sorbo, Claudia Filippini, Luciana Mascia, Antonio Pesenti, Alberto Zangrillo, Luciano Gattinoni, V. Marco Ranieri

Published in: Intensive Care Medicine | Issue 3/2012

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Abstract

Purpose

To assess whether partitioning the elastance of the respiratory system (E RS) between lung (E L) and chest wall (E CW) elastance in order to target values of end-inspiratory transpulmonary pressure (PPLATL) close to its upper physiological limit (25 cmH2O) may optimize oxygenation allowing conventional treatment in patients with influenza A (H1N1)-associated ARDS referred for extracorporeal membrane oxygenation (ECMO).

Methods

Prospective data collection of patients with influenza A (H1N1)-associated ARDS referred for ECMO (October 2009–January 2010). Esophageal pressure was used to (a) partition respiratory mechanics between lung and chest wall, (b) titrate positive end-expiratory pressure (PEEP) to target the upper physiological limit of PPLATL (25 cmH2O).

Results

Fourteen patients were referred for ECMO. In seven patients PPLATL was 27.2 ± 1.2 cmH2O; all these patients underwent ECMO. In the other seven patients, PPLATL was 16.6 ± 2.9 cmH2O. Raising PEEP (from 17.9 ± 1.2 to 22.3 ± 1.4 cmH2O, P = 0.0001) to approach the upper physiological limit of transpulmonary pressure (PPLATL = 25.3 ± 1.7 cm H2O) improved oxygenation index (from 37.4 ± 3.7 to 16.5 ± 1.4, P = 0.0001) allowing patients to be treated with conventional ventilation.

Conclusions

Abnormalities of chest wall mechanics may be present in some patients with influenza A (H1N1)-associated ARDS. These abnormalities may not be inferred from measurements of end-inspiratory plateau pressure of the respiratory system (PPLATRS). In these patients, titrating PEEP to PPLATRS may overestimate the incidence of hypoxemia refractory to conventional ventilation leading to inappropriate use of ECMO.
Appendix
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Metadata
Title
ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure
Authors
Salvatore Grasso
Pierpaolo Terragni
Alberto Birocco
Rosario Urbino
Lorenzo Del Sorbo
Claudia Filippini
Luciana Mascia
Antonio Pesenti
Alberto Zangrillo
Luciano Gattinoni
V. Marco Ranieri
Publication date
01-03-2012
Publisher
Springer-Verlag
Published in
Intensive Care Medicine / Issue 3/2012
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI
https://doi.org/10.1007/s00134-012-2490-7

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