Personalized Ventilator Settings for Patients on ECMO (PEEPECMO)

Personalized Ventilator Settings for Patients on ECMO (PEEPECMO)

While mechanical ventilation can be used to sustain life in those with lung injury, it, can further worsen lung injury or prevent lung healing resulting in high morbidity and mortality as seen in Acute Respiratory Distress Syndrome (ARDS).

Using extracorporeal membrane oxygenation (ECMO), the highest level of life support also known as the heart-lung machine, investigators may minimize injury from mechanical ventilation to allow the lungs to heal; however, the optimal ventilator strategies while on ECMO are unknown. This study will evaluate personalized ventilator strategy compared to standard of care ventilation.

Study Overview

• Status: Not yet recruiting
• Conditions: Extracorporeal Membrane Oxygenation; Acute Respiratory Distress Syndrome (ARDS); Ventilator Induced Lung Injury; Respiratory Failure, ICU; Respiratory Failure Patients Treated With ECMO
• Intervention / Treatment: Device: Personalized Positive End-Expiratory Pressure (PEEP)

Detailed Description

While mechanical ventilation can be used to sustain life in those with severe ARDS, it, can further worsen lung injury or prevent lung healing resulting in high morbidity and mortality. Using ECMO, investigators may be able to minimize injury from mechanical ventilation to allow the lungs to to recover from ARDS; however, the optimal ventilator settings and therapies are unknown while on ECMO. This trial will randomize patients to personalized ventilator strategy vs. standard of care.

Current ventilator guidelines while on V-V ECMO for ARDS use a one-size-fits-all approach - respiratory rate 10, driving pressure 10, and a PEEP of 10. Our central hypothesis is that personalized PEEP adjusted by measuring intrathoracic pressures via esophageal manometry (Pes) will decease ventilator induced lung injury (VILI) as assessed by biomarkers of inflammation (main outcomes IL-6 and sRAGE).

To carry out these aims, participants with ARDS on V-V ECMO will be prospectively randomize patients to two groups:

Control Arm: PEEP of 10 cmH2O (ECMO guidelines). Intervention Arm: PEEP guided by esophageal manometry. Both arms will have be on neuromuscular blockade, with a respiratory rate set at 10 breaths/min and a driving pressure of 10 cmH2O.

In addition to biomarkers of VILI, investigators will assess differences in other physiological outcomes including pulmonary mechanics and gas exchange.

Hypothesis: Personalized PEEP will have improvement in biomarkers (primary outcome - IL-6 and sRAGE), oxygenation, decreased dead space, and respiratory mechanics.

• Study Type: Interventional
• Enrollment (Estimated): 62
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Mazen F Odish, M.D.; Phone Number: 858-657-7023; Email: modish@health.ucsd.edu
• Study Contact Backup: Name: Robert L Owens, M.D.; Phone Number: 858-657-5258; Email: rowens@health.ucsd.edu

Study Locations

• United States
  • California
    • La Jolla, California, United States, 92037
      • UC San Diego Health Jacobs Medical Center
      • Contact: Mazen F Odish, M.D.; Phone Number: 8586577023; Email: modish@health.ucsd.edu
      • Contact: Robert L Owens, M.D.; Email: rowens@health.ucsd.edu

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

1. History of Lung or Cardiac Transplantation, or definite bridge to transplantation
2. Patient is not committed to full support
3. Treating clinician refusal, or unwillingness to commit to controlled therapeutics (Esophageal Pressure Guided Positive End-Expiratory Pressure and neuromuscular blockade)
4. Inability to get informed consent from the patient or legally authorized representative (LAR)

5. Patients with contraindications to esophageal balloon placement or inability to successfully place an esophageal balloon will have personalized PEEP determined by electrical impedance tomography.

   a. Contraindications include recently treated or bleeding varices, esophageal stricture, hematemesis, esophageal trauma, recent esophageal surgery or other contraindication for nasogastric tube placement, or severe coagulopathy.

6. Severe barotrauma that requires lower mean airway pressure (i.e., PEEP) per the treating physician.
7. Patients who are pregnant or prisoners.
8. Has been on V-V ECMO > 72 hours.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: Standard of Care Ventilator Settings while on ECMO; Classic ventilator settings for patients on ECMO. Pressure control, with a respiratory rate of 10, driving pressure of 10, and PEEP of 10.
Experimental: Personalized PEEP; Classic ventilator settings for patients on ECMO. Pressure control, with a respiratory rate of 10, driving pressure of 10, and a personalized PEEP (intervention)	Device: Personalized Positive End-Expiratory Pressure (PEEP); The personalized Positive End-Expiratory Pressure (PEEP) will be determined by esophageal manometry or electrical impedance tomography (EIT); Other Names: Esophageal manometry; Titration of PEEP by end-expiratory transpulmonary pressure; Titration of PEEP by electrical impedance tomography (EIT)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Biomarker outcomes (IL-6 and sRAGE)	IL-6 is a marker of systemic inflammation, previously used in studies of ECMO and ARDS. sRAGE is a marker of systemic inflammation and acute lung injury, previously used in studies of ECMO and ARDS.	Baseline at enrollment, 24±12 hours post enrollment, 48±12 hours post enrollment, 72±12 hours post enrollment, and end of ECMO run.
Respiratory gas exchange (dead space, oxygenation).	Arterial oxygenation (mmHg) will be assessed with the arterial blood gas. Deadspace fraction (unitless) will be calculated by the end-title CO2 monitoring.	Baseline at enrollment, 24±12 hours post enrollment, 48±12 hours post enrollment, 72±12 hours post enrollment.
Respiratory mechanics (compliance of the respiratory system, tidal volume, and imaging)	Compliance (ml/cmH2O) and tidal volumes (milliliters) will be measured by the ventilator. Imaging assessed will be the daily chest x-ray.	Baseline at enrollment, 24±12 hours post enrollment, 48±12 hours post enrollment, and 72±12 hours post enrollment.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Exploratory plasma, urine, and respiratory biomarkers.	Exploratory plasma biomarkers include but are not limited to: angiopoietin-1, angiopoietin-2; chemokind ligand-9, interferon-α; interferon γ-inducible protein-10, tumor necrosis factor α, vascular endothelial growth factor levels, etc.	Baseline at enrollment, 24±12 hours post enrollment, 48±12 hours post enrollment, 72±12 hours post enrollment, and end of ECMO run.

Collaborators and Investigators

• Sponsor: University of California, San Diego
• Collaborators: National Heart, Lung, and Blood Institute (NHLBI)
• Investigators: Principal Investigator: Mazen F Odish, M.D., University of California, San Diego

Publications and helpful links

General Publications

• Combes A, Hajage D, Capellier G, Demoule A, Lavoue S, Guervilly C, Da Silva D, Zafrani L, Tirot P, Veber B, Maury E, Levy B, Cohen Y, Richard C, Kalfon P, Bouadma L, Mehdaoui H, Beduneau G, Lebreton G, Brochard L, Ferguson ND, Fan E, Slutsky AS, Brodie D, Mercat A; EOLIA Trial Group, REVA, and ECMONet. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018 May 24;378(21):1965-1975. doi: 10.1056/NEJMoa1800385.
• Talmor D, Sarge T, Malhotra A, O'Donnell CR, Ritz R, Lisbon A, Novack V, Loring SH. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med. 2008 Nov 13;359(20):2095-104. doi: 10.1056/NEJMoa0708638. Epub 2008 Nov 11.
• Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM, Constantin JM, Courant P, Lefrant JY, Guerin C, Prat G, Morange S, Roch A; ACURASYS Study Investigators. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010 Sep 16;363(12):1107-16. doi: 10.1056/NEJMoa1005372.
• Beitler JR, Sarge T, Banner-Goodspeed VM, Gong MN, Cook D, Novack V, Loring SH, Talmor D; EPVent-2 Study Group. Effect of Titrating Positive End-Expiratory Pressure (PEEP) With an Esophageal Pressure-Guided Strategy vs an Empirical High PEEP-Fio2 Strategy on Death and Days Free From Mechanical Ventilation Among Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2019 Mar 5;321(9):846-857. doi: 10.1001/jama.2019.0555.
• Brodie D, Slutsky AS, Combes A. Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications: A Review. JAMA. 2019 Aug 13;322(6):557-568. doi: 10.1001/jama.2019.9302.
• Dianti J, Tisminetzky M, Ferreyro BL, Englesakis M, Del Sorbo L, Sud S, Talmor D, Ball L, Meade M, Hodgson C, Beitler JR, Sahetya S, Nichol A, Fan E, Rochwerg B, Brochard L, Slutsky AS, Ferguson ND, Serpa Neto A, Adhikari NKJ, Angriman F, Goligher EC. Association of Positive End-Expiratory Pressure and Lung Recruitment Selection Strategies with Mortality in Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-analysis. Am J Respir Crit Care Med. 2022 Jun 1;205(11):1300-1310. doi: 10.1164/rccm.202108-1972OC.
• Schmidt M, Pham T, Arcadipane A, Agerstrand C, Ohshimo S, Pellegrino V, Vuylsteke A, Guervilly C, McGuinness S, Pierard S, Breeding J, Stewart C, Ching SSW, Camuso JM, Stephens RS, King B, Herr D, Schultz MJ, Neuville M, Zogheib E, Mira JP, Roze H, Pierrot M, Tobin A, Hodgson C, Chevret S, Brodie D, Combes A. Mechanical Ventilation Management during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. An International Multicenter Prospective Cohort. Am J Respir Crit Care Med. 2019 Oct 15;200(8):1002-1012. doi: 10.1164/rccm.201806-1094OC.
• Tonna JE, Abrams D, Brodie D, Greenwood JC, Rubio Mateo-Sidron JA, Usman A, Fan E. Management of Adult Patients Supported with Venovenous Extracorporeal Membrane Oxygenation (VV ECMO): Guideline from the Extracorporeal Life Support Organization (ELSO). ASAIO J. 2021 Jun 1;67(6):601-610. doi: 10.1097/MAT.0000000000001432.
• Lam MTY, Duttke SH, Odish MF, Le HD, Hansen EA, Nguyen CT, Trescott S, Kim R, Deota S, Chang MW, Patel A, Hepokoski M, Alotaibi M, Rolfsen M, Perofsky K, Warden AS, Foley J, Ramirez SI, Dan JM, Abbott RK, Crotty S, Crotty Alexander LE, Malhotra A, Panda S, Benner CW, Coufal NG. Dynamic activity in cis-regulatory elements of leukocytes identifies transcription factor activation and stratifies COVID-19 severity in ICU patients. Cell Rep Med. 2023 Feb 21;4(2):100935. doi: 10.1016/j.xcrm.2023.100935. Epub 2023 Jan 25.
• Odish MF, Yang J, Cheng G, Yi C, Golts E, Madani M, Pollema T, Owens RL. Treatment of Bronchopleural and Alveolopleural Fistulas in Acute Respiratory Distress Syndrome With Extracorporeal Membrane Oxygenation, a Case Series and Literature Review. Crit Care Explor. 2021 May 14;3(5):e0393. doi: 10.1097/CCE.0000000000000393. eCollection 2021 May.
• Odish M, Pollema T, Meier A, Hepokoski M, Yi C, Spragg R, Patel HH, Alexander LEC, Sun XS, Jain S, Simonson TS, Malhotra A, Owens RL. Very Low Driving-Pressure Ventilation in Patients With COVID-19 Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation: A Physiologic Study. J Cardiothorac Vasc Anesth. 2023 Mar;37(3):423-431. doi: 10.1053/j.jvca.2022.11.033. Epub 2022 Nov 28.

Study record dates

Study Major Dates

• Study Start (Estimated): September 1, 2026
• Primary Completion (Estimated): June 30, 2030
• Study Completion (Estimated): June 30, 2031

Study Registration Dates

• First Submitted: June 27, 2025
• First Submitted That Met QC Criteria: June 22, 2026
• First Posted (Actual): June 29, 2026

Study Record Updates

• Last Update Posted (Actual): June 29, 2026
• Last Update Submitted That Met QC Criteria: June 22, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Keywords: Pneumonia; Influenza; ARDS; COVID; ECMO; Acute Respiratory Distress Syndrome; Respiratory failure; Viruses; PEEP; Lung injury; Positive end expiratory pressure; Personalized ventilator settings
• Additional Relevant MeSH Terms: Wounds and Injuries; Respiratory Tract Infections; Infections; Orthomyxoviridae Infections; RNA Virus Infections; Respiratory Tract Diseases; Lung Diseases; Respiration Disorders; Thoracic Injuries; Influenza, Human; Respiratory Distress Syndrome; Respiratory Insufficiency; Pneumonia; Virus Diseases; Lung Injury; Ventilator-Induced Lung Injury
• Other Study ID Numbers: 805593; 1K23HL181397 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES

IPD Plan Description

The data will be archived at the NHLBI BioData Catalyst (biodatacatalyst.nhlbi.nih.gov), which is an NIH repository for heart, lung, blood, and sleep research.

Data will be made available for investigators subject to submission of a data access and subsequent approval by the BioData Catalyst. The approval will be contingent upon several factors, including verification of the investigator having valid scientific rationale and relevant institutional review board approval.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: Yes