Suggested initial mechanical ventilation targets during V-V ECMO for ARDS

Parameter	Target	Notes
Plateau pressure (Pplat)^[1]	≤24 cm H₂O	May choose to go lower, if feasible
Driving pressure (Pplat-PEEP)^[1]	≤14 cm H₂O
Tidal volume	Adjust for goal of Pplat	Typically ≤4 mL/kg PBW, often much lower
Respiratory rate	≤10 breaths per minute	Sedation, with or without neuromuscular blockade, is often needed to achieve this goal Increased sweep flow may be needed to treat resultant hypercapnia Rationale is that lower respiratory rates are likely to reduce ventilator-induced lung injury
PEEP^[1]	≥10 cm H₂O	Refer to text for circumstances that may warrant particularly high levels of PEEP
FIO₂^[1]	0.3 to 0.5	Higher FIO₂ may be necessary if unable to achieve adequate oxygenation with ECMO Adequate oxygen delivery is the primary goal, not a particular peripheral oxygen saturation

V-V: venovenous; ECMO: extracorporeal membrane oxygenation; ARDS: acute respiratory distress syndrome; Pplat: plateau airway pressure; PEEP: positive end-expiratory pressure; PBW: predicted body weight; FiO₂: fraction of inspired oxygen.

Reference:

These recommended targets are based on the ventilator protocol of the intervention arm of the EOLIA trial: Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med 2018; 378:1965.

Modified and reprinted with permission of the American Thoracic Society. Copyright © 2023 American Thoracic Society. All rights reserved. Abrams D, Schmidt M, Pham T, et al. Mechanical ventilation for acute respiratory distress syndrome during extracorporeal life support. Research and practice. Am J Respir Crit Care Med 2020; 201:514. The American Journal of Respiratory and Critical Care Medicine is an official journal of the American Thoracic Society.

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Suggested initial mechanical ventilation targets during V-V ECMO for ARDS