Morini F, Goldman A, Pierro A
Department of Paediatric Surgery, Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust, London, UK.
Eur J Pediatr Surg. 2006 Dec;16(6):385-91. doi: 10.1055/s-2006-924751.
The aim of this study was to evaluate the evidence supporting the use of extracorporeal membrane oxygenation (ECMO) in infants with congenital diaphragmatic hernia (CDH) and severe respiratory failure.
Medline, Embase, ISI Current Contents and Biosis databases were searched using a defined strategy. Case reports and opinion articles were excluded. We performed: 1) a systematic review of non randomised studies comparing mortality when ECMO was not available with a period when ECMO was available. Mortality was classified as "early" (before hospital discharge) and "late" (after discharge). Patients were classified as "ECMO" and "non-ECMO" candidates according to criteria reported by the authors; 2) a meta-analysis of randomised controlled trials (RCTs) comparing ECMO and conventional mechanical ventilation (CMV). Differences in mortality are reported as relative risk (RR) and 95 % confidence intervals.
A) SYSTEMATIC REVIEW: 658 studies and 21 (2043 patients) fulfilled the entry criteria. Both early (RR 0.60 [0.51-0.70]; p < 0.001) and late mortality (RR 0.63 [0.53-0.73]; p < 0.001) were significantly lower when ECMO was available than when ECMO was unavailable. This difference in mortality was observed in "ECMO candidates" (RR 0.46 [0.32-0.68]; p < 0.001) but not in "non-ECMO candidates" (RR 0.80 [0.58-1.10]; p = 0.17). B) META-ANALYSIS: 3 trials comparing ECMO and conventional ventilation were identified which included 39 infants with CDH. The early mortality was significantly lower with ECMO compared to CMV (RR 0.73 [95 % CI 0.55-0.99]; p < 0.04), however, late mortality was similar in the two groups (RR 0.83 [0.66-1.05]; p = 0.12).
Non randomised studies suggest a reduction in mortality with ECMO. However, differences in the indications for ECMO and improvements in other treatment modalities may contribute to this reduction. The meta-analysis of RCTs indicates a reduction in early mortality with ECMO but no long-term benefit. A large RCT in infants with CDH and severe respiratory failure is warranted.
本研究旨在评估支持体外膜肺氧合（ECMO）用于先天性膈疝（CDH）合并严重呼吸衰竭婴儿的证据。
采用既定策略检索Medline、Embase、ISI当前目录和Biosis数据库。排除病例报告和观点文章。我们进行了：1）对非随机研究的系统评价，比较ECMO不可用时与可用时的死亡率。死亡率分为“早期”（出院前）和“晚期”（出院后）。根据作者报告的标准将患者分为“ECMO”和“非ECMO”候选者；2）对比较ECMO和传统机械通气（CMV）的随机对照试验（RCT）进行荟萃分析。死亡率差异以相对风险（RR）和95%置信区间报告。
A）系统评价：658项研究中有21项（2043例患者）符合纳入标准。ECMO可用时的早期死亡率（RR 0.60 [0.51 - 0.70]；p < 0.001）和晚期死亡率（RR 0.63 [0.53 - 0.73]；p < 0.001）均显著低于ECMO不可用时。在“ECMO候选者”中观察到死亡率的这种差异（RR 0.46 [0.32 - 0.68]；p < 0.001），但在“非ECMO候选者”中未观察到（RR 0.80 [0.58 - 1.10]；p = 0.17）。B）荟萃分析：确定了3项比较ECMO和传统通气的试验，其中包括39例CDH婴儿。与CMV相比，ECMO的早期死亡率显著降低（RR 0.73 [95%CI 0.55 - 0.99]；p < 0.04），然而，两组的晚期死亡率相似（RR 0.83 [0.66 - 1.05]；p = 0.12）。
非随机研究表明ECMO可降低死亡率。然而，ECMO适应症的差异以及其他治疗方式的改进可能导致了这种死亡率的降低。RCT的荟萃分析表明ECMO可降低早期死亡率，但无长期益处。有必要对CDH合并严重呼吸衰竭的婴儿进行一项大型RCT。
