Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; University Health Network and Sinai Health System, Toronto, ON Canada.
Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, The Pulmonary Center, Evans Center for Implementation and Improvement Sciences, and Department of Health Law, Policy and Management, Boston University School of Medicine, Boston, MA, USA.
Lancet Respir Med. 2019 Feb;7(2):163-172. doi: 10.1016/S2213-2600(18)30452-1. Epub 2019 Jan 11.
Use of extracorporeal membrane oxygenation (ECMO) in adults with severe acute respiratory distress syndrome has increased in the past 10 years. However, the efficacy of venovenous ECMO in people with acute respiratory distress syndrome is uncertain according to the most recent data. We aimed to estimate the effect of venovenous ECMO on mortality from acute respiratory distress syndrome.
In this systematic review and meta-analysis, we searched MEDLINE (including MEDLINE In-Process and Epub Ahead of Print), Embase and the Wiley search platform in the Cochrane database for randomised controlled trials and observational studies with matching of conventional mechanical ventilation with and without venovenous ECMO in adults with acute respiratory distress syndrome. Titles, abstracts, and full-text articles were screened in duplicate by two investigators. Data for study design, patient characteristics, interventions, and study outcomes were abstracted independently and in duplicate. Studies were weighted with the inverse variance method and data were pooled via random-effects modelling. We calculated risk ratios (RRs) and 95% CIs to summarise results. The primary outcome was 60-day mortality across randomised controlled trials. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines were used to rate the quality of evidence FINDINGS: We included five studies, two randomised controlled trials and three observational studies with matching techniques (total N=773 patients). In the primary analysis, which included two randomised controlled trials with a total population of 429 patients, 60-day mortality was significantly lower in the venovenous ECMO group than in the control group (73 [34%] of 214 vs 101 [47%] of 215; RR 0·73 [95% CI 0·58-0·92]; p=0·008; I 0%). The GRADE level of evidence for this outcome was moderate. Three studies included data for the incidence of major haemorrhage in the ECMO group. 48 (19%) of the 251 patients in these three studies had major haemorrhages.
Compared with conventional mechanical ventilation, use of venovenous ECMO in adults with severe acute respiratory distress syndrome was associated with reduced 60-day mortality. However, venovenous ECMO was also associated with a moderate risk of major bleeding. These findings have important implications surrounding decision making for management of severe acute respiratory distress syndrome at centres providing venovenous ECMO.
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在过去的 10 年中，体外膜肺氧合（ECMO）在成人严重急性呼吸窘迫综合征中的应用有所增加。然而，根据最新数据，静脉-静脉 ECMO 在急性呼吸窘迫综合征患者中的疗效尚不确定。我们旨在评估静脉-静脉 ECMO 对急性呼吸窘迫综合征死亡率的影响。
在这项系统评价和荟萃分析中，我们检索了 MEDLINE（包括 MEDLINE 处理中和 Epub 提前打印）、Embase 和 Cochrane 数据库中的 Wiley 搜索平台，以寻找随机对照试验和观察性研究，这些研究将急性呼吸窘迫综合征成人的常规机械通气与静脉-静脉 ECMO 进行了匹配。两名研究人员对标题、摘要和全文文章进行了重复筛选。独立并重复提取研究设计、患者特征、干预措施和研究结果的数据。使用逆方差法对研究进行加权，并通过随机效应模型对数据进行汇总。我们计算了风险比（RR）和 95%置信区间（CI）以总结结果。主要结局是随机对照试验的 60 天死亡率。使用推荐评估、制定和评估（GRADE）指南来评估证据质量。
我们纳入了五项研究，其中两项为随机对照试验，三项为匹配技术的观察性研究（总 N=773 例患者）。在包括两项随机对照试验的主要分析中，共纳入了 429 例患者，静脉-静脉 ECMO 组的 60 天死亡率明显低于对照组（73 [34%]例 214 例 vs 101 [47%]例 215 例；RR 0.73 [95%CI 0.58-0.92]；p=0.008；I 0%）。该结局的 GRADE 证据水平为中级。三项研究纳入了 ECMO 组主要出血发生率的数据。这三项研究中的 251 例患者中有 48 例（19%）发生了主要出血。
与常规机械通气相比，严重急性呼吸窘迫综合征成人使用静脉-静脉 ECMO 与降低 60 天死亡率相关。然而，静脉-静脉 ECMO 也与中等风险的大出血相关。这些发现对提供静脉-静脉 ECMO 的中心在严重急性呼吸窘迫综合征管理方面的决策具有重要意义。
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