1 Department of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Canada.
2 Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
Am J Respir Crit Care Med. 2018 Apr 15;197(8):991-993. doi: 10.1164/rccm.201711-2216CP.
We identified 810 reports that describe extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS), and 61 fulfilled our inclusion criteria. The authors of 26 (43%) reports responded to e-mail requests for confirmation (or clarification). Based on the aggregate (published and e-mailed) information, unambiguous data were available relating to 17 papers. These 17 papers represented 672 patients with ARDS who were cannulated with venovenous ECMO; of these patients, 208 (31%) received a trial of prone positioning before ECMO, and 464 (69%) did not. A key randomized controlled trial was published in 2013 that reported a survival benefit associated with prone positioning (N Engl J Med 2013;368:2159-2168). The proportion of all venovenous ECMO patients in whom prone positioning was used before ECMO was lower in studies published after 2013 (84 of 452 [19%]) than in those published before 2013 (116 of 210 [55%]) (P < 0.05). These data suggest a systematic bias in the reporting of outcomes after ECMO in the literature. The vast majority of reported patients who received ECMO did not first receive therapy that (in contrast to ECMO) is simple, cheap, and of proven benefit; therefore, inferences about the efficacy of ECMO in ARDS are of limited use.
我们共检索到 810 篇关于体外膜肺氧合（ECMO）在急性呼吸窘迫综合征（ARDS）中的应用的报告，其中 61 篇符合我们的纳入标准。有 26 篇（43%）报告的作者回复了电子邮件请求以确认（或澄清）。基于汇总的（已发表和已发送电子邮件的）信息，有 17 篇论文可提供明确的数据。这 17 篇论文共纳入了 672 例接受静脉-静脉 ECMO 治疗的 ARDS 患者；其中，208 例（31%）在 ECMO 前接受了俯卧位通气试验，464 例（69%）未接受。2013 年发表了一项关键的随机对照试验，该试验报道俯卧位通气与生存获益相关（N Engl J Med 2013;368:2159-2168）。与 2013 年之前发表的研究相比，2013 年之后发表的研究中接受 ECMO 前俯卧位通气的所有静脉-静脉 ECMO 患者比例较低（452 例中的 84 例[19%]），而 2013 年之前发表的研究中接受 ECMO 前俯卧位通气的患者比例较高（210 例中的 116 例[55%]）（P < 0.05）。这些数据表明，文献中 ECMO 后结局的报告存在系统偏倚。接受 ECMO 的绝大多数患者未首先接受（与 ECMO 相比）简单、廉价且已证实有效的治疗；因此，关于 ECMO 在 ARDS 中的疗效的推论用途有限。
