Munshi Laveena, Telesnicki Teagan, Walkey Allan, Fan Eddy
1 Interdepartmental Division of Critical Care, University Health Network, and.
Ann Am Thorac Soc. 2014 Jun;11(5):802-10. doi: 10.1513/AnnalsATS.201401-012OC.
Extracorporeal life support (ECLS) for acute respiratory failure has increased as a result of technological advancements and promising results from recent studies as compared with historical trials.
Systematically review the effect of ECLS compared with mechanical ventilation on mortality, length of stay, and adverse events in respiratory failure.
Data sources included were MEDLINE, EMBASE, and CENTRAL (through to October 2013). Any randomized controlled trial (RCT) or observational study comparing ECLS to mechanical ventilation in adults was used. Two authors independently abstracted the data. Our primary outcome was mortality. Secondary outcomes included intensive care unit length of stay, hospital length of stay, and adverse events. A sensitivity analysis was performed restricted to RCTs and quasi-RCTs, and a number of predefined subgroups were identified to explore heterogeneity.
Ten studies (four RCTs, six observational studies, 1,248 patients) were included. There was no significant difference in hospital mortality with ECLS as compared with mechanical ventilation (risk ratio [RR], 1.02; 95% confidence interval [CI], 0.79-1.33; I(2) = 77%). When restricted to venovenous ECLS studies of randomized trials and quasi-randomized trials (three studies; 504 patients), there was a decrease in mortality with ECLS compared with mechanical ventilation (RR, 0.64; 95% CI, 0.51-0.79; I(2) = 15%). There were insufficient study-level data to evaluate most secondary outcomes. Bleeding was significantly greater in the ECLS group (RR, 11.44; 95% CI, 3.11-42.06; I(2) = 0%). In the H1N1 subgroup (three studies; 364 patients), ECLS was associated with significantly lower hospital mortality (RR, 0.62; 95% CI, 0.45-0.8; I(2) = 25%).
ECLS was not associated with a mortality benefit in patients with acute respiratory failure. However, a significant mortality benefit was seen when restricted to higher-quality studies of venovenous ECLS. Patients with H1N1-acute respiratory distress syndrome represent a subgroup that may benefit from ECLS. Future studies are needed to confirm the efficacy of ECLS as well as the optimal configuration, indications, and timing for adult patients with respiratory failure.
由于技术进步以及与既往试验相比近期研究取得的良好结果，用于急性呼吸衰竭的体外生命支持（ECLS）有所增加。
系统评价与机械通气相比，ECLS对呼吸衰竭患者死亡率、住院时间及不良事件的影响。
纳入的数据来源包括MEDLINE、EMBASE和CENTRAL（截至2013年10月）。使用任何比较成人ECLS与机械通气的随机对照试验（RCT）或观察性研究。两位作者独立提取数据。我们的主要结局是死亡率。次要结局包括重症监护病房住院时间、医院住院时间和不良事件。进行了仅限于RCT和半RCT的敏感性分析，并确定了一些预定义亚组以探讨异质性。
纳入10项研究（4项RCT、6项观察性研究，共1248例患者）。与机械通气相比，ECLS组的医院死亡率无显著差异（风险比[RR]为1.02；95%置信区间[CI]为0.79 - 1.33；I² = 77%）。当仅限于随机试验和半随机试验的静脉 - 静脉ECLS研究时（3项研究；504例患者），与机械通气相比，ECLS组的死亡率有所降低（RR为0.64；95%CI为0.51 - 0.79；I² = 15%）。评估大多数次要结局的研究水平数据不足。ECLS组的出血情况显著更严重（RR为11.44；95%CI为3.11 - 42.06；I² = 0%）。在甲型H1N1亚组（3项研究；364例患者）中，ECLS与显著更低的医院死亡率相关（RR为0.62；95%CI为0.45 - 0.8；I² = 25%）。
ECLS对急性呼吸衰竭患者并无死亡率获益。然而，在仅限于高质量的静脉 - 静脉ECLS研究时，可观察到显著的死亡率获益。甲型H1N1急性呼吸窘迫综合征患者是可能从ECLS中获益的亚组。未来需要开展研究以证实ECLS的疗效以及成年呼吸衰竭患者的最佳配置、适应证和时机。
