Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition.
Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris Cedex 13, France.
Curr Opin Crit Care. 2019 Feb;25(1):71-76. doi: 10.1097/MCC.0000000000000567.
To summarize results of the most recent trials on venovenous extracorporeal membrane oxygenation (VV-ECMO) in severe acute respiratory distress syndrome (ARDS) and to elaborate on the unmet needs regarding VV-ECMO management in this setting.
Although it was terminated early for futility (i.e., failure to demonstrate a difference in 60-day mortality of 20%), the ECMO to Rescue Lung Injury in Severe ARDS trial of VV-ECMO for severe ARDS reported a nonsignificant, but clinically important, reduction in mortality (35 vs. 46%; relative risk 0.76; 95% confidence interval 0.55-1.04, P = 0.09). Refractory hypoxemia led to rescue ECMO in 28% of controls, who had more severe ARDS at inclusion, were extremely sick at the time of ECMO cannulation and for whom mortality was 57%. Beyond the rescue of patients dying of refractory hypoxemia, ECMO may now be used early in severe ARDS patients to reduce the intensity of mechanical ventilation and to minimize ventilator-induced lung injury. Future research in the field should focus on identification of patients who are more likely to benefit from this technique and the right timing for its initiation, optimization of daily management of patients under ECMO to further reduce complications, and selection of optimal ventilator management on ECMO.
VV-ECMO is a reasonable therapeutic option for patients with severe ARDS and major hypoxemia or excessive pressures. Future trials should be designed to optimize patients' management while on VV-ECMO support.
目的综述最近关于严重急性呼吸窘迫综合征（ARDS）患者静脉-静脉体外膜肺氧合（VV-ECMO）治疗的临床试验结果，并详细阐述在这种情况下 VV-ECMO 管理中尚未满足的需求。
最近发现尽管因无效而提前终止（即未能证明 60 天死亡率有 20%的差异），但 VV-ECMO 治疗严重 ARDS 以挽救肺损伤的 ECMO 挽救严重 ARDS 试验报告了死亡率的非显著但具有临床意义的降低（35%对 46%；相对风险 0.76；95%置信区间 0.55-1.04，P=0.09）。在对照组中，28%的患者因难治性低氧血症而需要进行挽救性 ECMO，这些患者在纳入时 ARDS 更严重，在 ECMO 置管时病情非常严重，死亡率为 57%。除了挽救因难治性低氧血症而死亡的患者外，ECMO 现在可能在严重 ARDS 患者中早期使用，以降低机械通气的强度，并尽量减少呼吸机引起的肺损伤。该领域的未来研究应集中在确定更有可能从该技术中获益的患者，以及启动该技术的最佳时机，优化 ECMO 下患者的日常管理以进一步减少并发症，以及选择最佳的 ECMO 通气管理。
总之，VV-ECMO 是严重 ARDS 患者伴严重低氧血症或过高压力的合理治疗选择。未来的试验应设计为优化患者在 VV-ECMO 支持下的管理。
