Department of Anesthesiology and Intensive Care Medicine, General University Hospital of Patras, School of Medicine, University of Patras, Rion, 26504 Patras, Greece.
Technological Educational Institute of Western Greece, Patras, Greece.
Biomed Res Int. 2019 Sep 29;2019:1035730. doi: 10.1155/2019/1035730. eCollection 2019.
Despite the use of lung protective ventilation (LPV) strategies, a severe form of acute respiratory distress syndrome (ARDS) is unfortunately associated with high mortality rates, which sometimes exceed 60%. Recently, major technical improvements have been applied in extracorporeal life support (ECLS) systems, but as these techniques are costly and associated with very serious adverse events, high-quality evidence is needed before these techniques can become the "cornerstone" in the management of moderate to severe ARDS. Unfortunately, evaluation of previous randomized controlled and observational trials revealed major methodological issues. In this review, we focused on the most important clinical trials aiming at a final conclusion about the effectiveness of ECLS in moderate to severe ARDS patients. Totally, 20 published clinical studies were included in this review. Most studies have important limitations with regard to quality and design. In the 20 included studies (2,956 patients), 1,185 patients received ECLS. Of them, 976 patients received extracorporeal membrane oxygenation (ECMO) and 209 patients received extracorporeal carbon dioxide removal (ECCOR). According to our results, ECLS use was not associated with a benefit in mortality rate in patients with ARDS. However, when restricted to higher quality studies, ECMO was associated with a significant benefit in mortality rate. Furthermore, in patients with H1N1, a potential benefit of ECLS in mortality rate was apparent. Until more high-quality data are derived, ECLS should be an option as a salvage therapy in severe hypoxemic ARDS patients.
尽管采用了肺保护性通气（LPV）策略，但严重的急性呼吸窘迫综合征（ARDS）仍与高死亡率相关，死亡率有时超过 60%。最近，体外生命支持（ECLS）系统采用了重大技术改进，但由于这些技术成本高且存在非常严重的不良事件，因此需要高质量的证据，这些技术才能成为管理中重度 ARDS 的“基石”。不幸的是，对以前的随机对照和观察性试验的评估显示出重大的方法学问题。在这篇综述中，我们重点关注了旨在最终确定 ECLS 在中重度 ARDS 患者中的有效性的最重要临床试验。总共纳入了 20 项已发表的临床试验。大多数研究在质量和设计方面存在重要局限性。在纳入的 20 项研究（2956 名患者）中，有 1185 名患者接受了 ECLS。其中，976 名患者接受了体外膜氧合（ECMO），209 名患者接受了体外二氧化碳去除（ECCOR）。根据我们的结果，ECLS 使用与 ARDS 患者死亡率降低无关。然而，当仅限于高质量研究时，ECMO 与死亡率显著降低相关。此外，在 H1N1 患者中，ECLS 在死亡率方面可能有获益。在获得更多高质量数据之前，ECLS 应该是严重低氧性 ARDS 患者挽救性治疗的选择。
