An interventional study of Mechanical Power Targeted Ventilation in ARDS (Acute Respiratory Distress Syndrome) and VV ECMO, sponsored by University of Virginia. Not yet recruiting at 1 site in United States. Open to participants aged 18 Years and older. Per ClinicalTrials.gov, last updated 2026-09-01.
Sponsored by University of Virginia · Not applicable, Interventional, and Treatment
The purpose of this study is to find a better way to protect the lungs of patients with Acute Respiratory Distress Syndrome (ARDS) who are being treated with a mechanical ventilator in addition to an extracorporeal membrane oxygenation (ECMO) machine. ARDS is a serious lung condition that makes it hard to breathe. People with ARDS often need care in the intensive care unit (ICU) and can become very sick with high mortality rates despite optimal care.
Doctors usually support patients with through ARDS with a breathing machine called a ventilator. The ventilator helps lungs imitate taking small breaths to help protect the lungs from more damage, however ventilator induced lung injury (VILI) can still contribute significantly to organ injury.
For patients in whom a ventilator is not enough support due to the severity of their lung disease, veno-venous (VV) ECMO can fully support the lungs while they recover. In these sickest patients, it is important to avoid causing more lung damage with the ventilator. Protecting the lungs may help them heal faster and may also help protect other parts of the body. More people are now being treated with VV ECMO, but there is still not enough research to know which ventilator settings are safest and work best. Most current recommendations are based on doctors' experience instead of research studies. This study will help researchers learn the best way to use ventilators for patients on VV ECMO and improve their recovery.
Acute respiratory distress syndrome (ARDS) is a common intensive care unit (ICU) admission diagnosis with mortality nearing 50% in severe cases. Traditional management focuses on lung protective ventilation consisting of low tidal volumes while limiting plateau and driving pressures. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a guideline recommended intervention for patients with severe ARDS refractory to other interventions. The optimal lung protective ventilation strategy for patients supported by VV-ECMO is unknown.
Over the past few decades, significant effort in the form of multiple international, multicenter, randomized controlled trials have evaluated lung protective ventilation strategies in ARDS, highlighted by the ARMA trial which showed an 8.8% absolute mortality reduction with low tidal volume ventilation and limiting plateau pressure to \<30 cmH2O compared to standard of care at the time. These trials have helped define lung protective ventilation parameters over the past few decades, leading to significant improvements in mortality over that time. For patients with respiratory failure refractory enough to require VV ECMO support, avoiding further ventilator induced lung injury (VILI) is paramount to optimize the chances of lung recovery and avoid extrapulmonary organ dysfunction. However, despite the rapid increase in the utilization of VV ECMO for severe respiratory failure, very little prospective or randomized research has attempted to evaluate what constitutes lung protective ventilation in this patient population. In the absence of any current randomized trial evidence, management guidelines rely on expert opinion alone. These guidelines are extrapolated from lung protective ventilation studied in patients undergoing conventional mechanical ventilation despite significant differences introduced by the presence of the ECMO circuit, most notably the ability of the circuit to assume most if not all of the pulmonary support while enabling ultra-low tidal volume "lung rest" ventilation with tidal volumes of 3-4 cc/kg predicted body weight (PBW), limiting plateau pressures to ≤ 24 cmH2O but no greater than 30 cmH2O, and maintaining a respiratory rate of 4-15 breaths/minute but no greater than 30. Notably, the largest prospective observational trial of patients supported by VV ECMO for respiratory failure did not suggest an outcome benefit for any of these single traditionally targeted ventilator variables. Given the increasing utilization of VV ECMO for ARDS, there is a need for prospective evaluation of a more comprehensive approach to ventilator management as a means to minimize VILI and improve outcomes in this critically ill patient population.
Mechanical power (MP) attempts to more comprehensively unify all ventilator-related causes of lung injury such as distending pressure, tidal volume, flow, and respiratory rate into a single, quantifiable variable. Thus, MP is an innovative approach to more comprehensively reducing VILI compared to traditional tidal volume or plateau targets, providing a potential new benchmark for enhanced lung-protective ventilation. MP has been independently associated with poor patient outcomes even with low tidal volume and driving pressure in multiple studies in patients with and without ARDS, as well as ECMO and non-ECMO supported patient populations across numerous retrospective and observational studies. However, despite this strong correlation, the feasibility of prospectively evaluating a MP-based strategy in a randomized fashion remains unknown. The aim of this trial is to evaluate the feasibility, safety, and tolerability of a MP-targeted ventilation protocol in patients with severe ARDS requiring VV ECMO support as the first step in ultimately evaluating the ability of such a strategy to directly impact and improve patient-oriented outcomes.
Description of Study Intervention:
After randomization, patients will subsequently be assigned to either a low mechanical power target (2-4 J/min) or usual care. This range was chosen as it closely mirrors the power of normal breathing in healthy subjects and falls on the lower range of that reported in retrospective and observational trials, indicating potential feasibility. As a part of the protocol, patients in both arms will meet the current standard of care regarding the individual parameters of ultra-lung protective ventilation and "lung rest" while on VV-ECMO as it is currently defined. The low mechanical power target arm will follow a well-defined mechanical ventilator management algorithm to meet the assigned target, as described below. Patients in the usual care arm will be managed at the discretion of the treating intensivist with care, including mechanical ventilation settings, sedation, VV ECMO, and additional adjunct therapies, reflecting current best practice guidelines.
For patients assigned to the intervention arm, the patient will be placed on volume control (VC) or pressure control (PC) ventilation with either an initial tidal volume of 3-4cc/kg predicted body weight (PBW) (for VC) or inspiratory pressure required to reach the same tidal volume goal (for PC), FiO2 set between 0.30-0.50, and a PEEP of at least 10. This tidal volume or inspiratory pressure, for VC and PC ventilation respectively, will then be titrated down to meet a goal plateau pressure of less than or equal to 24 cmH2O, and a target driving pressure no greater than 14 cmH2O. Finally, the respiratory rate will then be titrated between 1 and 15 to meet the specified mechanical power goal range. Once the respiratory rate has been lowered to 8, tidal volumes (or inspiratory pressure required to meet this goal) will be lowered to 3cc/kg PBW prior to further reductions in respiratory rate. MP will be calculated every two hours and adjusted as needed to stay within the goal MP range until pre-specified weaning criteria are met.
382 studies on the registry are indexed under Acute Lung Injury; 73 are open to participants now.
This study's planned enrollment of 24 is below the median of 60 across 227 interventional studies indexed under Acute Lung Injury.
Browse Acute Lung Injury studies →University of Virginia is the lead sponsor of 675 studies on the registry; 138 are open to participants now.
Of its 61 completed or terminated interventional studies of FDA-regulated products, 42 (69%) have results posted.
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Severe ARDS as the primary etiology of respiratory failure defined by:
Exclusion Criteria
This arm will receive routine care for all aspects of care including ECMO and mechanical ventilation as decided by the attending physician.
This group will have their mechanical ventilator settings adjusted by the study team to a target mechanical power of between 2-4 J/minute, closely mimicking the mechanical power of that required for healthy adult breathing. The adjustments will be made using the mechanical power ventilation formula with information specific to the person, titrating each of the variables historically associated with ventilator induced lung injury in tandem. The ventilator will be monitored and adjusted as needed every 2 hours for 7 days while patients are on ECMO.
Procedure: Mechanical Power Targeted Ventilation
For patients assigned to the intervention arm, the patient will be placed on volume control (VC) or pressure control (PC) ventilation with either an initial tidal volume of 3-4cc/kg predicted body weight (PBW) (for VC) or inspiratory pressure required to reach the same tidal volume goal (for PC), FiO2 set between 0.30-0.50, and PEEP of at least 10. This tidal volume or inspiratory pressure, for VC and PC respectively, will then be titrated down to meet a goal plateau pressure of less than or equal to 24 cmH2O, and a target driving pressure no greater than 14 cmH2O. Finally, the respiratory rate will then be titrated between 1 and 15 to meet the specified mechanical power goal range. Once the respiratory rate has been lowered to 8, tidal volumes will be lowered to 3cc/kg PBW prior to further reductions in respiratory rate. Mechanical power (MP) will be calculated every two hours and adjusted as needed to stay within the goal MP range until pre-defined weaning criteria are met.
Feasibility of prospective, randomized mechanical power-based strategy to establish a causal relationship between MP and clinical outcomes.
The primary outcome is to assess the feasibility of the intervention protocol, as assessed by the number of patients adhering to mechanical power (MP) protocol, with a target adherence of \>/= 90% of the intervention time spent within the assigned mechanical power range.
Time frame: From enrollment to the end of the intervention window of 7 days.
To evaluate the safety of a total lung protective ventilation strategy utilizing a mechanical power targeted strategy versus conventional ultra-low tidal volume ventilation.
Secondary outcome one: safety, as measured by the incidence of refractory hypoxemia and/or hypercarbia occurring during intervention window as defined by a sustained PaO2 of \<50 mmHg or saturation \<85% on two arterial blood gases drawn \>30 minutes apart and for hypercarbia as sustained PaCO2 \>65 mmHg with associated respiratory acidosis noted by a pH \< 7.20 on two arterial blood gases drawn \>30 minutes apart. Reported as number of patients in whom either incidence occurred at least one time during intervention window.
Time frame: From enrollment to end of intervention window of 7 days
To evaluate the tolerability of a total lung protective ventilation strategy utilizing a mechanical power targeted strategy versus conventional ultra-low tidal volume ventilation.
Second outcome measure: Tolerability; as measured by sedative requirements as assessed by daily the Richmond Agitation-Sedation Scale (RASS) ranging from -5 to +4 with lower scores indicating a need for deeper sedation and less tolerability. Reported as median numerical score with interquartile range (IQR).
Time frame: From enrollment to end of intervention window of 7 days
To evaluate the tolerability of a total lung protective ventilation strategy utilizing a mechanical power targeted strategy versus conventional ultra-low tidal volume ventilation.
Second outcome measure: Tolerability; as measured by requirement for use of continuous neuromuscular blockade. Reported as median number of days with interquartile ranges for which a patient requires continuous neuromuscular blockade for greater than four hours. A lower median number of days receiving continuous neuromuscular blockade indicates greater tolerability.
Time frame: From enrollment to end of intervention window of 7 days
Surfactant Protein D (SP-D)
Additional exploratory outcome: Biomarkers; This will include the impact on physiologic markers of VILI via serial measurements of plasma biomarker: Surfactant Protein D, reported in pg/mL from days 0-7.
Time frame: From enrollment to end of intervention window at day 7.
Duration of ECMO Support
Additional outcomes: ECMO; This will include the duration of ECMO support as reported by ECMO free days by day 60.
Time frame: From enrollment to end of study participation (post hospitalization visit 12 weeks after discharge.)
Mortality
Additional outcome: Mortality; incidence of mortality as reported by incidence at by day 60.
Time frame: From enrollment to end of study participation (post hospitalization visit 12 weeks after discharge.)
Organ Failure Free Days
Additional outcome: Organ Failure; as reported by the number of organ failure-free days by day 28 defined as: absence of vasopressor support (cardiovascular), absence of invasive or noninvasive (HFNC or NIPPV) respiratory support (pulmonary), and absence of renal replacement therapy (renal) and reported as median number of days with interquartile ranges.
Time frame: From enrollment to end of study participation (post hospitalization visit 12 weeks after discharge.)
Soluble Receptor for Advanced Glycation Endproducts (sRAGE)
Additional exploratory outcome: Biomarkers; This will include the impact on physiologic markers of VILI via serial measurements of plasma biomarker Soluble Receptor for Advanced Glycation Endproducts, reported in pg/mL from days 0-7.
Time frame: From enrollment to end of intervention window at day 7
Interleukin-6 (IL-6)
Additional exploratory outcome: Biomarkers; This will include the impact on physiologic markers of VILI via serial measurements of plasma biomarker Interleukin-6, reported in pg/mL from days 0-7.
Time frame: From enrollment to end of intervention window at day 7
Interleukin-8 (IL-8)
Additional exploratory outcome: Biomarkers; This will include the impact on physiologic markers of VILI via serial measurements of plasma biomarker Interleukin-8, reported in pg/mL from days 0-7.
Time frame: From enrollment to end of intervention window at day 7
Interleukin-18 (IL-18)
Additional exploratory outcome: Biomarkers; This will include the impact on physiologic markers of VILI via serial measurements of plasma biomarker Interleukin-18, reported in pg/mL from days 0-7.
Time frame: From enrollment to end of intervention window at day 7
Tumor Necrosis Factor-alpha (TNF-alpha)
Additional exploratory outcome: Biomarkers; This will include the impact on physiologic markers of VILI via serial measurements of plasma biomarker Tumor Necrosis Factor-alpha, reported in pg/mL from days 0-7.
Time frame: From enrollment to end of intervention window at day 7
Soluble Intercellular Adhesion Molecule-1 (sICAM-1)
Additional exploratory outcome: Biomarkers; This will include the impact on physiologic markers of VILI via serial measurements of plasma biomarker Soluble Intercellular Adhesion Molecule-1, reported in pg/mL from days 0-7.
Time frame: From enrollment to end of intervention window at day 7
Angiopoietin-2 (Ang-2)
Additional exploratory outcome: Biomarkers; This will include the impact on physiologic markers of VILI via serial measurements of plasma biomarker Angiopoietin-2, reported in pg/mL from days 0-7.
Time frame: From enrollment to end of intervention window at day 7
PDFs hosted by the registry, ClinicalTrials.gov.
Plan to share: Yes — All de-identified IPD that underlie results in a publication.
Supporting information: Study protocol, Statistical analysis plan, Informed consent form
Time frame: Beginning 3 months and ending 2 years after the publication of results.
Data sharing details ↗ · health-research-uva.rdexchange.org
Start is estimated for Sep 2026; primary completion for Sep 2028, 24 months later.
Of 51 non-industry interventional studies with no phase under Acute Lung Injury, half reached primary completion within 15 months of starting (the median), counting those still running; a quarter within 7 and three quarters within 34. This study's planned 24 months is above that.
Counting every sponsor, half of 52 studies reached it within 15 months; a quarter within 7 and three quarters within 34.
How these figures are worked out, and which studies are left out of them.
This study is not yet recruiting, as verified in Aug 2026. You cannot join it, but the record below documents what was studied.
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