Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain.
Shock, Organ Dysfunction and Resuscitation Research Group (SODIR), Vall d'Hebron Research Institute, Barcelona, Spain.
Ann Am Thorac Soc. 2024 Mar;21(3):449-455. doi: 10.1513/AnnalsATS.202306-572OC.
Severe cases of acute respiratory distress syndrome (ARDS) may require prolonged (>28 d) extracorporeal membrane oxygenation (ECMO). In nonresolving disease, recovery is uncertain, and lung transplant may be proposed. This study aims to identify the variables influencing survival and to describe the functional status of these patients at 6 months. This was a retrospective, multicenter, observational cohort study including patients requiring ECMO support for coronavirus disease (COVID-19)-related ARDS for >28 days. Multivariate analysis was performed using Cox regression in preselected variables and in least absolute shrinkage and selection operator selected variables. In a analysis to account for confounders and differences in awake strategy use by centers, treatment effects of the awake strategy were estimated using an augmented inverse probability weighting estimator with robust standard errors clustered by center. Between March 15, 2020 and March 15, 2021, 120 patients required ECMO for >28 days. Sixty-four patients (53.3%) survived decannulation, 62 (51.7%) were alive at hospital discharge, and 61 (50.8%) were alive at 6-month follow-up. In the multivariate analysis, age (1.09; 95% confidence interval [CI], 1.03-1.15; = 0.002) and an awake ECMO strategy (defined as the patient being awake, cooperative, and performing rehabilitation and physiotherapy with or without invasive mechanical ventilation at any time during the extracorporeal support) (0.14; 95% CI, 0.03-0.47; = 0.003) were found to be predictors of hospital survival. At 6 months, 51 (42.5%) patients were at home, 42 (84.3%) of them without oxygen therapy. A cutoff point of 47 ECMO days had a 100% (95% CI, 76.8-100%) sensitivity and 60% (95% CI, 44.3-73.6%) specificity for oxygen therapy at 6 months, with 100% specificity being found in 97 days. Patients with COVID-19 who require ECMO for >28 days can survive with nonlimiting lung impairment. Age and an awake ECMO strategy may be associated with survival. Longer duration of support correlates with need for oxygen therapy at 6 months.
严重的急性呼吸窘迫综合征（ARDS）病例可能需要长时间（>28 天）的体外膜肺氧合（ECMO）支持。在非缓解疾病中，恢复情况不确定，可能需要进行肺移植。本研究旨在确定影响生存的变量，并描述这些患者在 6 个月时的功能状态。这是一项回顾性、多中心、观察性队列研究，纳入了因 COVID-19 相关 ARDS 而需要 ECMO 支持>28 天的患者。使用 Cox 回归对预先选择的变量和最小绝对收缩和选择算子选择的变量进行多变量分析。在 分析中，为了考虑混杂因素和中心之间清醒策略使用的差异，使用增强逆概率加权估计器和稳健标准误差聚类中心来估计清醒策略的治疗效果。2020 年 3 月 15 日至 2021 年 3 月 15 日，120 例患者需要 ECMO 支持>28 天。64 例（53.3%）患者成功脱机，62 例（51.7%）患者出院时存活，61 例（50.8%）患者在 6 个月随访时存活。多变量分析显示，年龄（1.09；95%置信区间 [CI]，1.03-1.15； = 0.002）和清醒 ECMO 策略（定义为患者在任何时候清醒、合作，并进行康复和物理治疗，同时使用或不使用有创机械通气）（0.14；95% CI，0.03-0.47； = 0.003）是影响医院生存的预测因素。在 6 个月时，51 例（42.5%）患者在家中，其中 42 例（84.3%）无需吸氧治疗。6 个月时氧疗的截断值为 47 ECMO 天，灵敏度为 100%（95% CI，76.8-100%），特异性为 60%（95% CI，44.3-73.6%），97 天特异性为 100%。需要 ECMO 支持>28 天的 COVID-19 患者可以存活且肺部损伤不限制活动。年龄和清醒 ECMO 策略可能与生存相关。更长的支持时间与 6 个月时需要氧疗相关。
