Acute and Critical Care 2022 May 37(2):159-167

https://doi.org/10.4266/acc.2021.00927

Association of pulmonary arterial pressure with volume

status in patients with acute respiratory distress syndrome
receiving extracorporeal membrane oxygenation
Tae Hwa Hong1, Hyoung Soo Kim2, Sunghoon Park3

Departments of 1Surgery, 2Cardiothoracic Surgery, and 3Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea

Background: Data on pulmonary hemodynamic parameters in patients with acute respiratory dis-
tress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) are scarce. Original Article
Methods: The associations between pulmonary artery catheter parameters for the first 7 days of
ECMO, fluid balance, and hospital mortality were investigated in adult patients (aged ≥19 years) Received: July 6, 2021
who received venovenous ECMO for refractory ARDS between 2015 and 2017. Revised: September 28, 2021
Results: Twenty patients were finally included in the analysis (median age, 56.0 years; interquartile Accepted: September 30, 2021
range, 45.5–68.0 years; female, n=10). A total of 140 values were collected for each parameter (i.e.,
Corresponding author
7 days×20 patients). Net fluid balance was weakly but significantly correlated with systolic and di-
Sunghoon Park
astolic pulmonary arterial pressures (PAPs; r=0.233 and P=0.011; r=0.376 and P<0.001, respective-
Department of Pulmonary, Allergy
ly). Among the mechanical ventilation parameters, above positive end-expiratory pressure was and Critical Care Medicine, Hallym
correlated with systolic PAP (r=0.191 and P=0.025), and static compliance was negatively correlat- University Sacred Heart Hospital, 22
ed with diastolic PAP (r=−0.169 and P=0.048). Non-survivors had significantly higher systolic PAPs Gwanpyeong-ro 170beon-gil,
than in survivors. However, in multivariate analysis, there was no significant association between Dongan-gu, Anyang 14068, Korea
mean systolic PAP and hospital mortality (odds ratio, 1.500; 95% confidence interval, 0.937–2.404; Tel: +82-31-380-3715
P=0.091). Fax: +82-31-380-3973
Conclusions: Systolic PAP was weakly but significantly correlated with net fluid balance during E-mail: [email protected]
the early ECMO period in patients with refractory ARDS receiving ECMO.

Key Words: body fluids; extracorporeal membrane oxygenation; pulmonary artery; respiratory dis-
tress syndrome

INTRODUCTION
Acute respiratory distress syndrome (ARDS) is frequently complicated by pulmonary hyper-
tension [1,2], and many studies have documented the changes in pulmonary hemodynamic Copyright © 2022 The Korean Society of
Critical Care Medicine
parameters in patients with ARDS. Some have reported that systolic pulmonary arterial pres-
sure (PAP) or mean PAP is a significant indicator of patient outcome [3,4], whereas others did This is an Open Access article distributed
under the terms of Creative Attributions
not find any associations or did not specifically evaluate the associations [2,5,6]. However, Non-Commercial License (https://
creativecommons.org/li-censes/by-nc/4.0/)
there is still uncertainty about the underlying pathophysiology between the degree of pulmo- which permits unrestricted noncommercial
use, distribution, and reproduction in any
nary hypertension (or pulmonary vascular dysfunction) and patient outcome. medium, provided the original work is
Routine use of a pulmonary artery catheter (PAC) is not currently recommended because properly cited.

https://www.accjournal.org 159
Hong TH, et al. PAP in patients with ARDS receiving ECMO

of the lack of clinical benefit and possible complications [7,8].

However, PACs provide unique and various information to KEY MESSAGES
intensivists and often change therapy, particularly regarding ■ Net fluid balance was weakly but significantly correlat-
fluid management and vasopressor use in critically ill patients. ed with systolic and diastolic pulmonary arterial pres-
sure (PAP) in patients with refractory acute respiratory
In particular, fluid balance has been considered important in
distress syndrome receiving extracorporeal membrane
terms of patients’ outcomes [8-10]. oxygenation.
Recently, extracorporeal membrane oxygenation (ECMO) ■ Systolic PAP was higher in non-survivors than in survi-
has been widely used as salvage therapy for patients with severe vors, but was not associated with hospital mortality in
ARDS. Many authors investigated mechanical ventilation (MV) multivariable analysis.
parameters associated with patient outcomes [11-13]. How-
ever, data on pulmonary hemodynamic parameters are very
scarce for these patients. Therefore, in this retrospective study, under fluoroscopic guidance. The 17- to 19-Fr (for return)
we investigated the association between PAP, fluid balance, and and 21-Fr (for drainage) cannulas were placed (DLP and
in-hospital mortality in patients in whom a PAC was inserted Bio-Medicus, Medtronic, Minneapolis, MN, USA; RMI,
after initiating venovenous (VV) ECMO for refractory ARDS. Edward’s Life sciences, Irvine, CA, USA). After ECMO was
initiated, the pump flow was adapted (3–5 L/min) to main-
MATERIALS AND METHODS tain adequate oxygen (SpO2 >88%), and the sweep gas flow
was titrated to maintain a PaCO2 of 40 mm Hg (usually 1:1 to
Study Population and Design blood flow). During ECMO support, heparin was used for an-
This was a retrospective study using data collected from adult ticoagulation, with a target activated partial thromboplastin
patients (age ≥19 years) who received VV ECMO for refractory time of 1.5 times the normal range. MV settings were adjusted
ARDS between January 2015 and January 2017. This study was to enable lung-protective ventilation after the initiation of
performed in a single center (tertiary hospital) where annual ECMO, according to general recommendations [18,19]: tidal
ECMO volume was 60 cases (VV ECMO, 20 cases). During volume <6 ml/kg predicted body weight, PEEP ≥5 cm H2O,
the study period, a PAC was inserted for hemodynamic mon- and peak inspiratory pressure < 30 cm H2O. ECMO weaning
itoring in patients for whom written consent was obtained. was considered when the patient became hemodynamically
The Berlin definition was used for diagnosing ARDS [14]. The stable and showed evidence of pulmonary improvement. The
indications for VV ECMO were severe hypoxemia (e.g., PaO2/ pump flow was first tapered to 2 L/min, and the sweep gas to
FiO2 <150) with a high positive end-expiratory pressure (PEEP 0 L/min; decannulation was indicated if the patient tolerated
>10 cm H2O), uncompensated severe hypercapnia (pH <7.20), these settings [15-17]. ECMO weaning was considered suc-
or excessively high peak inspiratory pressure or plateau pres- cessful when the patient remained stable for 24 hours without
sure, despite standard of care management with a MV [15-17]. ECMO support. MV weaning was undertaken in accordance
The exclusion criteria were patients with cardiopulmonary with the general recommendations [20].
resuscitation; do-not-resuscitate order; ECMO treatment for
respiratory failure other than ARDS; incomplete data on PAC PAC Insertion and Fluid Management
parameters; and those who were transferred to other hospitals PACs (7.5-Fr; Edwards Lifesciences, Irvine, CA, USA) were in-
during the ECMO treatment. serted, using a balloon-flotation catheter in bedside, through
This study was approved by the Institutional Review Board the internal jugular vein within the first 2 hours following ini-
of Hallym University (IRB No. 2020-06-22) and conducted in tiation of ECMO. Correct positioning of the catheter tip (i.e., in
accordance with the Declaration of Helsinki. Informed con- the pulmonary artery) was verified by chest radiography. Sys-
sent was waived due to the retrospective nature of the study. tolic and diastolic PAP was monitored continuously, and cardi-
ac output was measured by the thermodilution method using
ECMO and MV Strategies 10 mL of injected cold saline. The cardiac output value was the
We used Capiox EBS (Terumo, Tokyo, Japan) or PLS (Maquet, mean of four cardiac output measurements without artifacts
Hirrlingen, Germany) equipment. Both femoral veins were on the temperature curves; the cardiac index (CI) was the ratio
percutaneously cannulated using the Seldinger technique of cardiac output to the patient’s body surface area. Daily PAC

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Hong TH, et al. PAP in patients with ARDS receiving ECMO

data were collected between 9–10 AM. However, in our cohort, was used for all statistical analyses.
pulmonary artery occlusion pressure (PAOP) was not mea-
sured for safety reasons; instead, we used diastolic PAP values RESULTS
(for PAOP) to calculate pulmonary vascular resistance (PVR).
A stable relationship exists between diastolic PAP and PAOP Study Population
[1,21]. We used a target diastolic PAP of <20 cm H2O for fluid During the study period, 45 patients received ECMO for re-
management during ECMO treatment. Mean arterial pressure fractory ARDS; of these, 26 patients received a PAC (Figure 1).
(MAP) was maintained at >65 mm Hg and urine output >0.5 Twenty patients were finally included in the analysis. Their
ml/kg/hr; vasopressors were used if required. The decision to median age was 56.0 years (interquartile range [IQR], 45.5–
remove the PAC was at the discretion of the physician. The for- 68.0 years), and 10 patients were female. The median SOFA
mulas for the PAC parameters were as follows: score was 9.5 (IQR, 7.0–11.0), and 16 (80.0%) of the patients
Mean PAP=(systolic PAP+2×diastolic PAP)/3 had ARDS of pulmonary origin. Hypertension (20.0%) and
PVR (i.e., modified PVR)=(mean PAP–diastolic PAP)×80/ heart diseases (20.0%) were the most common comorbidities
cardiac output (Table 1).
Systemic vascular resistance=(MAP–central venous pres- One patient had a history of cor pulmonale, and pre-ECMO
sure)×80/cardiac output right systolic ventricular pressure was documented only in
six patients (48.0 mm Hg; IQR, 46.0–55.0). The median sys-
Data Collection and Analysis tolic blood pressure, heart rate, and respiratory rates before
The following data were obtained: demographic characteris- initiating ECMO were 134.0 mm Hg (IQR, 117.3–148.3 mm
tics (age and sex); comorbidities; causes of ARDS; laboratory Hg), 115.0 beats/min (IQR, 101.0–131.5 beats/min), and 26.0
parameters and severity-of-illness scores (Sequential Organ breaths/min (IQR, 21.3–31.5 breaths/min), respectively. The
Failure Assessment [SOFA]) before implementing ECMO; median duration of MV before initiating ECMO was 1.0 days
and data on MV parameters and fluid balance (input/output) (IQR, 0.5–2.0 days). The initial PAC parameters (ECMO day 1)
during the first 7 days of ECMO. Systolic and diastolic PAPs, are presented in Supplementary Table 1; the mean PAP was
the CI, systemic vascular resistance, PVR (i.e., modified PVR), 22.8 mm Hg (IQR, 20.1–27.8 mm Hg), and eight patients had
and central venous pressure were collected during the first 7 pulmonary hypertension (i.e., mean PAP >25 mm Hg). None of
days of ECMO. The rates of successful weaning from ECMO the patients underwent prone positioning before and during
and hospital death were investigated as patient outcomes. ECMO treatment.
The primary outcome was the association between systolic
and diastolic PAPs and hospital mortality, and the secondary
outcomes were the associations between systolic and diastol-
45 Patients who received VV ECMO
ic PAPs and daily net fluid balance (i.e., a total fluid balance
during the early seven ECMO days).

Statistical Analysis 26 Patients with PACs 19 Patients without PACs

All results are presented as numbers with percentages for
categorical variables, and as medians with interquartile rang-
2 Cardiopulmonary resuscitation
es for continuous variables. The Mann-Whitney U-test was 1 Respiratory failure other than ARDS
used to compare continuous variables, and the chi-square or 2 Incomplete PAC data
1 Transfer to other hospitals
Fisher’s exact test was employed to compare categorical vari-
ables. A multivariable logistic regression analysis, adjusted for
age, SOFA, fluid balance, and tidal volume, was performed to
11 Survivors 9 Non-survivors
investigate an independent association of a PAC parameter
(i.e., systolic PAP) with hospital mortality. All probability val-
Figure 1. Flowchart of patients enrolment. VV: venovenous; ECMO:
ues were two-sided and a P<0.05 was considered statistically extracorporeal membrane oxygenation; PAC: pulmonary arterial
significant. IBM SPSS ver. 25.0 (IBM Corp., Armonk, NY, USA) catheter; ARDS: acute respiratory distress syndrome.

Acute and Critical Care 2022 May 37(2):159-167 https://www.accjournal.org 161

Hong TH, et al. PAP in patients with ARDS receiving ECMO

Table 1. Baseline characteristics before ECMO treatment

Variable Survivor (n=11) Non-survivor (n=9) P-value
Age (yr) 49.0 (45.0–61.0) 68.0 (49.5–72.5) 0.112
Sex (male:female) 6:5 4:5 1.000
Comorbidity
Diabetes 2 (18.2) 1 (11.1) 1.000
Hypertension 3 (27.3) 1 (11.1) 0.591
Heart disease 1 (9.1) 3 (33.3) 0.285
Chronic kidney disease 0 1 (11.1) 0.450
Liver cirrhosis 1 (9.1) 0 1.000
Cancer 0 1 (11.1) 0.450
Reason for ECMO 0.591
Pulmonary origin 8 8
Non-pulmonary origin 3 1
SOFA score at admission 10.0 (8.0–14.0) 8.0 (7.0–10.0) 0.084
Respiratory SOFA score 4.0 (4.0–4.0) 4.0 (4.0–4.0) 0.668
PaO2/FiO2 ratio 85.6 (77.7–98.9) 98.9 (82.8–99.0) 0.208
White blood cell counts (103/µl) 13.2 (9.0–21.0) 16.7 (9.5–17.9) 0.882
Hemoglobin (g/dl) 11.9 (9.8–13.8) 11.0 (9.9–12.4) 0.503
Platelet (103/µl) 109.0 (59.0–163.0) 256.0 (147.5–281.0) 0.007
Bilirubin (mg/dl) 1.5 (0.3–2.8) 0.2 (0.2–1.1) 0.020
Albumin (g/dl) 3.0 (2.8–3.5) 2.8 (2.5–3.0) 0.131
Creatinine (mg/dl) 1.2 (0.8–1.3) 0.8 (0.5–1.3) 0.370
C-reactive protein (mg/L) 191.6 (160.4–292.3) 196.9 (108.1–209.5) 0.331
Brain natriuretic peptide (pg/ml) 342.0 (22.9–2898.0) 235.8 (61.6–489.7) 0.551
Vasopressor use 9 (81.8) 2 (22.2) 0.024
Ejection fraction (%) 60.0 (60.0–66.0) 60.0 (55.0–65.5) 0.969
MV setting before ECMO
Above PEEP (cm H2O) 15.0 (12.0–20.0) 18.0 (14.0–19.0) 0.878
PEEP (cm H2O) 10.0 (6.0–12.0) 14.0 (12.0–15.0) 0.083
Respiratory rate (breaths/min) 18.0 (12.0–26.0) 20.0 (18.0–28.0) 0.180
Values are presented as median (interquartile range) or number (%).
ECMO: extracorporeal membrane oxygenation; SOFA: Sequential Organ Failure Assessment; MV: mechanical ventilation; PEEP: positive end-expiratory pressure.

Treatments and Outcomes Correlation Analyses

The initial ECMO flow was 4.2 L/min (IQR, 3.9–4.5 L/min) A total of 140 samples were collected per parameter (i.e., 7
with a sweep gas flow of 4.0 L/min (IQR, 4.0–4.0 L/min). The days×20 patients). Net fluid balance was weakly but signifi-
median numbers of packed red blood cells and platelets trans- cantly correlated with systolic and diastolic PAPs (r=0.233
fused were 12.5 units (IQR, 8.0–15.5 units) and 28.5 units (IQR, and P=0.011; r=0.376 and P<0.001, respectively) (Figure 2,
0.0– 63.5 units), respectively, with no difference between sur- Table 2) and was negatively correlated with the CI (r=−0.205
vivors and non-survivors (data not shown). The MV settings and P=0.025). Among the MV parameters, above PEEP was
before initiating ECMO did not differ between the two groups correlated with systolic PAP (r=0.191 and P=0.025) (Table 3),
(Table 1). Fourteen patients (70.0%) were successfully weaned and static compliance (i.e., tidal volume/above PEEP in pres-
from ECMO and 11 (55.0%) survived to discharge; the medi- sure-controlled ventilation mode) was negatively correlated
an ECMO duration was 18.5 days (IQR, 10.0–27.0 days). The with diastolic PAP (r=−0.169 and P=0.048).
lengths of the intensive care unit (ICU) and hospital stays were
32.0 days (IQR, 26.0–42.8 days) and 42.5 days (IQR, 28.5–53.8 Univariate and Multivariate Analyses
days). None of the patients underwent lung transplantations. Among the PAC parameters, systolic PAP was significantly

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Hong TH, et al. PAP in patients with ARDS receiving ECMO

A Systolic PAP (mm Hg) B Diastolic PAP (mm Hg)

60 40

35
50
30
40
25

30 20

15
20
r=0.233 10 r=0.376
10 P=0.011 P<0.001
5

–6,000 –4,000 –2,000 0 2,000 4,000 6,000 8,000 –6,000 –4,000 –2,000 0 2,000 4,000 6,000 8,000
Net fluid balance Net fluid balance
Figure 2. Correlation analyses between pulmonary arterial pressures (PAPs) and net fluid balance during the first 7 extracorporeal membrane
oxygenation (ECMO) period. (A) Corrlation between systolic PAP and net fluid balance and (B) correlation between diastolic PAP and net fluid
balance. Gray line indicates trend line.

Table 2. Correlation of net fluid balance with PAC parameters during the early 7 ECMO days
Net fluid balance Cardiac index Systolic PAP Diastolic PAP PVR SVR CVP
r –0.205 0.233 0.376 0.038 0.048 0.213
P-value 0.025 0.011 <0.001 0.684 0.599 0.020
Formulas for PAC parameters: (1) mean PAP=(systolic PAP+2×diastolic PAP)/3; (2) PVR (i.e., modified PVR)=(mean PAP–diastolic PAP)×80/cardiac output; (3)
systolic vascular resistance=(MAP–CVP)×80/cardiac output; (4) cardiac index=cardiac output/body surface area.
PAC: pulmonary artery catheter; ECMO: extracorporeal membrane oxygenation; PAP: pulmonary artery pressure; PVR: pulmonary vascular resistance; SVR:
systemic vascular resistance; CVP: central venous pressure.

Table 3. Correlation of mechanical ventilation with PAC parameters during the early seven ECMO days
Variable Above PEEP PEEP Tidal volume Static compliance
Systolic PAP
r 0.191 –0.042 –0.038 –0.120
P-value 0.025 0.622 0.655 0.161
Diastolic PAP
r 0.162 0.162 –0.079 –0.169
P-value 0.058 0.058 0.356 0.048
Mean PAP
r 0.175 0.095 –0.061 –0.153
P-value 0.041 0.266 0.473 0.073
PVR
r 0.049 –0.123 –0.110 –0.040
P-value 0.568 0.152 0.194 0.645
SVR
r –0.111 0.155 –0.324 –0.171
P-value 0.195 0.070 <0.001 0.044
Cardiac index
r –0.013 –0.139 –0.021 –0.006
P-value 0.884 0.105 0.806 0.946
PAC: pulmonary artery catheter; ECMO: extracorporeal membrane oxygenation; PEEP: positive end-expiratory pressure; PAP: pulmonary artery pressure; PVR:
pulmonary vascular resistance; SVR: systemic vascular resistance.

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Hong TH, et al. PAP in patients with ARDS receiving ECMO

higher in non-survivors than in survivors (Table 4, Figure 3). PAPs in patients receiving VV ECMO for severe ARDS. Besides,
However, no significant differences were observed in daily systolic PAP was significantly higher in non-survivors than sur-
fluid balance (Supplementary Table 2) or MV parameters vivors. However, the mean systolic PAP value during the first
(Supplementary Table 3) between the two groups. In the mul- 7 days of ECMO was not significantly associated with hospital
tivariable model, five variables (age, SOFA, fluid balance, tidal mortality.
volume, and systolic PAP) were included (Table 5), and mean Previous large-scale randomized trials have demonstrat-
systolic PAP was not significantly associated with hospital mor- ed no survival benefit of PAC-guided therapy compared to
tality (odds ratio, 1.500; 95% confidence interval, 0.937–2.404). standard care (in surgical patients) or central venous cathe-
ter-guided therapy in those with acute lung injury [7,22,23].
DISCUSSION In particular, the PAC-guided therapy was associated with a
two-fold risk of catheter-related complications compared to
This retrospective study revealed that net fluid balance was central venous catheter-guided therapy [7]. Since then, the
weakly but significantly correlated with systolic and diastolic routine use of PAC has not been recommended. However, our

Table 4. PAC parameters between survivors and non-survivors during the early 7 days of ECMO (140 samples for each variable per group)
Survivor Non-survivor
Variable P-valuea
Median (IQR) Mean±SD Median (IQR) Mean±SD
Cardiac index (L/min/m2) 5.5 (4.1–6.8) 5.7±2.3 4.9 (4.0–5.9) 5.5±2.5 0.344
Systolic PAP (mm Hg) 29.0 (25.0–33.5) 29.8±7.2 33.0 (30.0–40.0) 35.0±7.8 <0.001
Diastolic PAP (mm Hg) 17.0 (14.5–20.5) 17.7±4.8 19.0 (14.0–23.0) 18.8±5.8 0.221
PVR (dyn∙sec/cm5) 55.0 (44.0–74.0) 58.7±27.3 65.0 (55.0–98.0) 73,4±34,4 0.006
SVR (dyn∙sec/cm5) 985.0 (790.0–1152.5) 1,007.3±320.5 838.0 (551.0–1183.0) 887.9±363.3 0.034
CVP (mm Hg) 10.0 (8.0–13.0) 10.6±3.4 10.0 (7.0–15.0) 10.7±4.9 0.875
PAC: pulmonary arterial catheter; ECMO: extracorporeal membrane oxygenation; IQR: interquartile range; SD: standard deviation; PAP: pulmonary artery
pressure; PVR: pulmonary vascular resistance; SVR: systemic vascular resistance; CVP: central venous pressure.
a
Mann-Whitney U-test (between survivors and non-survivors).

Non-survivor Non-survivor
A Survivor B Survivor
40.0 P=0.031 22.0
P=0.067

37.5
Mean diastolic PAP (mm Hg)
Mean systolic PAP (mm Hg)

P=0.046 20.0

35.0

18.0
32.5
P=0.067

30.0
16.0

27.5

14.0

1.00 2.00 3.00 4.00 5.00 6.00 7.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00
ECMO day ECMO day

Figure 3. Comparison of mean (A) systolic and (B) diastolic pulmonary arterial pressures (PAPs) between survivors and non-survivors. ECMO:
extracorporeal membrane oxygenation.

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Hong TH, et al. PAP in patients with ARDS receiving ECMO

Table 5. Univariable and multivariable analysis for hospital deatha

Univariable analysis Multivariable analysis
Variable
OR 95% CI P-value OR 95% CI P-value
Age 1.506 0.978–1.140 0.167 1.053 0.914– 1.214 0.475
SOFA 0.710 0.481–1.047 0.084 0.585 0.294–1.164 0.126
Fluid balanceb 1.122 0.999–1.260 0.051 1.000 1.000–1.000 0.222
Tidal volume 1.000 1.000–1.000 0.106 0.986 0.949–1.025 0.481
Systolic PAPc 1.234 0.992–1.536 0.060 1.500 0.937–2.404 0.091
OR: odds ratio; CI: confidence interval; SOFA: Sequential Organ Failure Assessment; PAP: pulmonary artery pressure; ECMO: extracorporeal membrane
oxygenation.
a
Hosmer-Lemeshow test, chi-square=8.044 and P=0.420; bNet fluid balance during the 7 ECMO days; cMean value of systolic PAP for each patient.

aim in this retrospective study was not to evaluate the useful- non-survivors in the study. Of importance, PVR is affected
ness of PAC but to investigate the therapeutic or prognostic mainly by factors that are intrinsic to the lung (e.g., lung injury
role of PAP in patients receiving ECMO for refractory ARDS. in ARDS), whereas PAP is affected not only by factors that are
We inserted PACs in patients undergoing VV ECMO to moni- intrinsic to the lung (e.g., PVR) but also by extrinsic factors
tor hemodynamics and guide conservative fluid management. (e.g., right ventricular function). This may have contributed
A relatively large volume of fluid was given to patients during to the different mortality results between the two parameters
the early period (e.g., days 1–3) (Supplementary Table 2), but [2]. In our analysis, diastolic PAP was used instead of PAOP
we tried to maintain a conservative strategy while monitoring to calculate PVR. Although we cannot conclusively state that
diastolic PAP and using diuretics. Although we did not find the PVR values in our study were correct, the PVRs were sig-
any strong associations due to small sample size, PAP may re- nificantly higher in non-survivors than in survivors during
flect fluid balance, and a higher systolic PAP might be associ- the first 7 days of ECMO (Table 4), which is consistent with
ated with higher mortality in patients receiving VV ECMO for previous data [1,26]. However, the presence of pulmonary
severe ARDS. These results are consistent with those reported vascular dysfunction is likely to be a simple marker of lung
previously [3,4]. injury severity. The causal relationship, as well as the exact
As noted above, we did not inflate the balloon of the PAC to mechanism, between pulmonary vascular dysfunction and
measure PAOP in our patients for safety reasons; occluding patient outcomes remains unclear.
the proximal pulmonary artery may be associated with an in- Previous studies have demonstrated that conservative fluid
creased risk of thromboembolism or rupture of the pulmonary management is important to the outcomes of patients with
artery in critically ill patients. Previous studies have reported ARDS, including those receiving ECMO [8,9]. In our cohort,
that the incidence rates of catheter-related infections or embo- net fluid balance did not differ during the early ECMO days
lization in patients with a PAC are 0%–4.6% or 1%–11%, respec- between survivors and non-survivors. However, interestingly,
tively [22-24]. No case of thromboembolic complications was systolic and diastolic PAPs were weakly but significantly cor-
detected in our cohort, but one patient (5.0%) had PAC-related related with net fluid balance (Table 2). These results suggest
bacteremia; however, the duration of PAC indwelling was lon- that if a new noninvasive method is validated in the future
ger than that reported in previous studies [22]. [27,28], systolic PAP could be a useful parameter for optimizing
ARDS elevates PAP and consequently increases right ven- fluid management or predicting patient outcomes. However,
tricular afterload, and this elevated pressure harms patient systolic PAP did not show any correlations with oxygenation
outcomes. Although data are still conflicting [2,5,6], some (initial PaO2/FiO2 ratio) and other outcomes (i.e., durations of
previous studies have reported the prognostic significance of ECMO and MV, and ICU and hospital length of stay).
PAP in patients with ARDS [1,3,4,25]. In a secondary analysis Regarding ventilator settings, above PEEP was correlated
of 501 patients from the Fluid and Catheter Treatment Trial with systolic PAP (Table 3). This implies that together with flu-
by the ARDS Network, the largest trial in the era of lung-pro- id balance, above PEEP may be a determining factor for PAP.
tective ventilation, a high transpulmonary gradient or PVR However, notably, lung compliance was also correlated with
was significantly associated with a poor outcome [1]; howev- diastolic PAP. When considering the association of diastolic
er, no difference was detected in PAP between survivors and PAP with fluid balance (Table 2), we may say that a negative (or

Acute and Critical Care 2022 May 37(2):159-167 https://www.accjournal.org 165

Hong TH, et al. PAP in patients with ARDS receiving ECMO

less) fluid balance can induce an increase in lung compliance. ACKNOWLEDGMENTS

However, contrary to a previous study [11], neither lung com-
pliance nor diastolic PAP was associated with hospital mortal- We would like to thank Dr. Seong-Sik Cho (Dong-A University
ity in our study population. More research is needed to clarify Hospital) for his dedication to the statistical analyses in the
this point. study.
To date, data on PAC parameters in patients receiving ECMO
for severe ARDS are very scarce. Hemmila et al. [6] reported ORCID
no difference in pre-ECMO systolic and diastolic PAPs be-
tween survivors and non-survivors. In contrast, Lazzeri et al. Tae Hwa Hong https://orcid.org/0000-0001-8701-5309
[29] found that survival is significantly associated with lower Hyoung Soo Kim https://orcid.org/0000-0001-6023-0818
pre-ECMO systolic PAP. We collected and analyzed PAC data Sunghoon Park https://orcid.org/0000-0001-7004-6985
obtained after initiating VV ECMO (during the first 7 days of
ECMO), which is one of the strengths of our study. Although AUTHOR CONTRIBUTIONS
our study was underpowered to verify a significant association
between systolic PAP and hospital mortality due to its small Conceptualization: THH, SP. Data curation: all authors. For-
sample size, the investigation of the role of PAPs seems rea- mal analysis: all authors. Methodology: all authors. Project
sonable in patients receiving ECMO, when considering many administration: SP. Visualization: THH, HSK. Writing–orig-
factors affecting pulmonary vascular function, such as volume inal draft: THH, SP. Writing–review & editing: all authors.
overload, vasopressors, and MV.
This study had several limitations. First, because of the small SUPPLEMENTARY MATERIALS
sample size and retrospective nature of the study, the results
may reflect unintended bias. In particular, half of the patients Supplementary materials can be found via https://doi.org/
did not receive a PAC during the study period. Second, as 10.4266/acc.2021.00927.
aforementioned, we did not measure PAOP directly but used
diastolic PAP to calculate PVR. Third, mean values for PAC REFERENCES
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