Strategies for Optimal Lung Ventilation in ECMO for ARDS: The SOLVE ARDS Study (SOLVE ARDS)

Due to lack of studies on mechanical ventilation strategies in patients with severe Acute Respiratory Distress Syndrome (ARDS) supported with Veno-Venous Extra-Corporeal Membrane Oxygenation (VV ECMO), ventilator settings in this patient population are set arbitrarily.

In this two-phases prospective, interventional, pilot study we hope to gain physiologically relevant data on two aspects of mechanical ventilation in patients with severe ARDS supported with VV ECMO: (1) the use of tidal ventilation and (2) the level of Positive End-Expiratory Pressure (PEEP).

1. PHASE 1: impact of tidal ventilation on VILI (10 patients) We hypothesized that a CPAP strategy that minimizes end-tidal pulmonary stress and strain mitigates VILI compared to the current mechanical ventilation practice that employs tidal ventilation in patients with severe ARDS on ECMO.

   In this first phase we will test whether administering a distending inspiratory pressure to produce tidal ventilation is superior to a strategy where only continuous positive airway pressure (CPAP) is applied for ventilation induced lung injury (VILI) mitigation, as assessed by its impact on biotrauma (serum cytokines) and physiologic measurements.

2. PHASE 2: impact of PEEP on VILI (10 patients) We also hypothesized that adjusting PEEP to maximize respiratory system compliance reduces VILI in patients with severe ARDS on ECMO.

In the second phase we will therefore gain more insight as to whether a strategy that utilizes a PEEP level that correspond to best compliance is beneficial over Zero End-Expiratory Pressure (ZEEP). We will test the impact of both strategies on biotrauma (serum cytokines), physiologic parameters, and right ventricular function (transesophageal echocardiographic assessment).

Because ARDS patients supported with VV ECMO can be hemodynamically unstable, the use of imaging techniques that require transport, such as computed tomography, is limited. Therefore, bedside imaging techniques, such as pleural and lung ultrasound (PLUS) and focused bedside cardiac ultrasonography, are important tools for clinicians who care for these patients. This study will allow us to learn whether these techniques are feasible and valid in this patient population.

Furthermore, the knowledge gained from this study will allow us to assess the rationale and feasibility of performing a similar larger, randomized study in the future.

Study Overview

• Status: Unknown
• Conditions: Respiratory Distress Syndrome, Adult
• Intervention / Treatment: Device: PHASE 1: impact of tidal ventilation on VILI; Device: PHASE 2: impact of PEEP on VILI

• Study Type: Interventional
• Enrollment (Anticipated): 20
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Canada
  • Ontario
    • Toronto, Ontario, Canada, M5G 2C4
      • Recruiting
      • Medical Surgical ICU - Toronto General Hospital
      • Contact: Eddy Fan, MD, PhD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (ADULT, OLDER_ADULT, CHILD)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Severe ARDS (Berlin Definition)
• VV ECMO < 72 hours
• Endotracheal intubation or tracheostomy

Exclusion Criteria:

• Thoracic surgery/lung transplantation during the current hospitalization
• Contraindications to a RM (MAP < 60 mmHg despite administration of fluids and vasopressors; Active air leak through a thoracostomy tube; Pneumothorax, or subcutaneous or mediastinal emphysema, (if chest tube has not been inserted))
• Contraindications to TEE
• Age < 16 years

Study Plan

How is the study designed?

Design Details

• Primary Purpose: SUPPORTIVE_CARE
• Allocation: NON_RANDOMIZED
• Interventional Model: CROSSOVER
• Masking: NONE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: PHASE 1: impact of tidal ventilation on VILI; In the first phase we will test whether administering a distending inspiratory pressure to produce tidal ventilation is superior to a strategy where only continuous positive airway pressure (CPAP) is applied for ventilation induced lung injury (VILI) mitigation, as assessed by its impact on biotrauma (serum cytokines) and physiologic measurements.	Device: PHASE 1: impact of tidal ventilation on VILI; PHASE 1A - Baseline - Standard Ventilation Protocol (PCV 10 cmH2O, PEEP 10 cmH2O, RR 10, FiO2 0.30) PHASE 1B - CPAP Strategy - CPAP 10 cmH2O for 1 hour PHASE 1C - Higher Tidal Ventilation Strategy (PCV 20 cmH2O, PEEP 10 cmH2O, RR 10, FiO2 0.30) PHASE 1D - Return to Baseline - Standard Ventilation Protocol
EXPERIMENTAL: PHASE 2: impact of PEEP on VILI; In the second phase we will gain more insight as to whether a strategy that utilizes a PEEP level that correspond to best compliance is beneficial over Zero End-Expiratory Pressure (ZEEP). We will test the impact of both strategies on biotrauma (serum cytokines), physiologic parameters, and right ventricular function (transesophageal echocardiographic assessment).	Device: PHASE 2: impact of PEEP on VILI; PHASE 2A - Baseline - Standard Ventilation Protocol - (PCV 10 cmH2O, PEEP 10 cmH2O, RR 10, FiO2 0.30) PHASE 2B - Decremental PEEP Trial PHASE 2C - CPAP set at best compliance of respiratory system (as per decremental PEEP Trial) PHASE 2D - ZEEP PHASE 2E - Return to Baseline - Standard Ventilation Protocol

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Ventilator-Induced Lung Injury (VILI) in patients with ARDS on ECMO ventilated with different strategies (tidal ventilation, CPAP, ZEEP), as measured by Serum Cytokines	1 hour after initiation of each experimental ventilation strategy

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Impact of a CPAP strategy (PEEP set at best compliance and at ZEEP) in patients with severe ARDS on ECMO, as measured by transesophageal echocardiography (TEE)	Quantification of RV function: RVEDA/LVEDA; LV end-diastolic/systolic eccentricity indexes:; 2D RVFAC; TAPSE; Tissue Doppler-derived tricuspid lateral annular systolic velocity (S'); RIMP; 3D EF < 44%; Myocardial Acceleration During Isovolumic Contraction; Regional RV Strain	30 minutes after initiation of experimental CPAP/ZEEP strategy
Feasibility and validity of focused cardiac ultrasound, as compared to TEE as gold standard, in the assessment of RV function in patients with ARDS on ECMO	Quantification of RV function: RVEDA/LVEDA; TAPSE; RV Annular Velocity (S'); LV end-diastolic and end-systolic eccentricity indexes	30 minutes after initiation of experimental CPAP/ZEEP strategy
Feasibility of lung ultrasound in patients with severe ARDS on ECMO	Lung Ultrasound Score	30 minutes after initiation of experimental CPAP/ZEEP strategy
Feasibility (patient recruitment, protocol adherence, physiologic tolerability)	This outcome will be assessed by: the ability to enrol the proposed patient sample within the timeframe of the study (24 months); >90% adherence to the experimental protocol on enrolled patients; >80% completion of the entire experimental protocol on enrolled patients	At overall study completion (i.e., 24 months from study start or after enrolment of last patient)

Collaborators and Investigators

• Sponsor: University of Toronto
• Collaborators: University Health Network, Toronto; The Physicians' Services Incorporated Foundation
• Investigators: Principal Investigator: Eddy Fan, MD, PhD, University Health Network, University of Toronto; Principal Investigator: Niall D. Ferguson, MD, MSc, University Health Network, University of Toronto

Study record dates

Study Major Dates

• Study Start: September 1, 2014
• Primary Completion (ANTICIPATED): December 1, 2015

Study Registration Dates

• First Submitted: November 6, 2013
• First Submitted That Met QC Criteria: November 14, 2013
• First Posted (ESTIMATE): November 21, 2013

Study Record Updates

• Last Update Posted (ESTIMATE): November 6, 2014
• Last Update Submitted That Met QC Criteria: November 5, 2014
• Last Verified: November 1, 2014

More Information

Terms related to this study

• Keywords: Ventilator-Induced Lung Injury; Ultrasonography; Extracorporeal Membrane Oxygenation; Pulmonary Heart Disease; Ventilators, Mechanical
• Additional Relevant MeSH Terms: Respiratory Tract Diseases; Respiration Disorders; Lung Diseases; Infant, Newborn, Diseases; Lung Injury; Infant, Premature, Diseases; Respiratory Distress Syndrome; Respiratory Distress Syndrome, Newborn; Acute Lung Injury
• Other Study ID Numbers: SOLVE ARDS_01