Flow-Controlled Ventilation May Reduce Mechanical Power and Increase Ventilatory Efficiency in Severe Coronavirus Disease-19 Acute Respiratory Distress Syndrome

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Abstract Background. The prevention of ventilator-induced lung injury is the mainstay of the management of mechanical ventilation in patients with acute respiratory distress syndrome (ARDS). Reducing mechanical power during invasive mechanical ventilation may be beneficial. Flow-controlled ventilation (FCV) (Evone®, Ventinova Medical, Eindhoven, The Netherlands) is a ventilatory mode providing low and controlled flow rates throughout both inspiration and expiration. We hypothesize that FCV would reduce mechanical power and ventilatory ratio, by allowing the reduction of minute ventilation, in coronavirus disease (COVID)-19 patients developing refractory hypoxemia despite optimization of conventional constant-flow volume-targeted mechanical ventilation (CMV) and prone positioning.Methods. The study was performed in the intensive care unit of the Vittorio Veneto Hospital (Italy). We included 10 sedated and paralyzed patients with ARDS secondary to COVID-19, with arterial partial pressure of oxygen to inspired oxygen fraction ratio (PaO2/FiO2) < 150 mmHg during CMV while in prone position for at least 12 consecutive hours. All measurements were obtained in CMV prior to switching to FCV (CMV1), after 4 hours of FCV, and then again after 4 hours of CMV (CMV2). Results. During FCV inspiratory flow rate, respiratory rate, and minute ventilation were significantly lower than with both CMV1 and CMV2. Mechanical power was 10.8 (9.9-13.4) J/min, as opposed to CMV1 [22.7 (20.3-25.6) J/min (p=0.006)] and CMV2 [20.1 (19.0-24.0) J/min (p=0.006)]. Ventilatory ratio also significantly decreased to 1.40 (1.28-1.44) from CMV1 [2.22 (1.90-2.56) (p=0.006)] and then increased again during CMV2 [2.20 (1.79-2.57) (p=0.006)]. Arterial partial pressure of carbon dioxide, pH, and PaO2/FiO2 were not significantly different among the three conditions.Conclusions. FCV reduced mechanical power and increased ventilatory efficiency in severely hypoxemic COVID-19 patients receiving CMV and prone positioning.

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