Lung protective ventilation limiting tidal volume and plateau pressure improves survival in ARDS. The application of positive end-expiratory pressure (PEEP) further stabilizes the lung by preventing alveolar collapse during expiration, thereby reducing cyclic atelectasis. However, the optimal approach to PEEP titration to minimize ventilator-induced lung injury (VILI) has not been delineated. The EPVent-1 trial demonstrated that esophageal pressure-guided PEEP titration was feasible and safe with a trend toward increased survival and improved oxygenation in mild to moderate ARDS. However, interest in esophageal manometry in ARDS was deflated by the more recent EPVent-2 trial demonstrating no improvement in a composite outcome incorporating mortality and ventilator-free days in patients with moderate to severe ARDS. A new randomized control trial published last week by Wang et al. examined the role of esophageal manometry-guided PEEP titration in a novel subset of severe ARDS patients treated with VV ECMO. 

A 52-year-old man with a history significant for hypertension presented to the emergency department with cough, dyspnea and fever. He progressed to severe acute respiratory distress syndrome (ARDS) secondary to COVID-19 pneumonia. He developed refractory hypoxemia with P/F < 60 mm Hg despite low tidal volume ventilation, paralysis, inhaled epoprostenol and prone positioning. Is this patient a candidate for venovenous ECMO and, if so, who should guide initiation and management of ECMO? The Society of Critical Care Medicine (SCCM) and Extracorporeal Life Support Organization (ELSO) recently published a position paper on the role of the intensivist in the initiation and management of ECMO. 

Venous thromboembolism is considered one of the most preventable causes of in-hospital death. Venovenous extracorporeal membrane oxygenation (VV ECMO) utilization for severe respiratory failure has increased in the decade following the 2009 influenza A H1N1 pandemic and the publication of the CESAR trial.¹ The interaction between a patient’s blood and the ECMO circuit produces an inflammatory response that can provoke both thrombotic and bleeding complications. In a systematic review of patients with H1N1 treated with VV ECMO published in 2013, the incidence of cannula-associated deep venous thrombosis (CaDVT) was estimated to be as low as 10 percent; however, more recent data suggests the incidence of venous thrombosis after decannulation is much higher. Additionally, a significant proportion of CaDVT are distal thrombi located in the vena cava, which would be missed with a traditional ultrasound diagnostic approach after decannulation from VV ECMO.