Acute hypoxaemic respiratory failure after treatment with lower tidal volume ventilation facilitated by extracorporeal carbon dioxide removal: long-term outcomes from the REST randomised trial

Abstract

IntroductionLower tidal volume ventilation, facilitated by veno-venous extracorporeal carbon dioxide removal (vv-ECCO2R), does not improve 90-day mortality in patients with acute hypoxaemic respiratory failure (AHRF). The aim of this analysis was to evaluate the effect of this therapeutic strategy on long-term outcomes.MethodsThis was a prespecified analysis of the REST trial, a UK-wide multicentre randomised clinical trial that compared lower tidal volume ventilation, facilitated by vv-ECCO2R (intervention), with standard care in the treatment of patients with moderate-to-severe AHRF. Mortality to 2 years was assessed, while respiratory function, post-traumatic stress disorder, cognitive function and health-related quality of life were evaluated in survivors at 1 year using standardised questionnaires.ResultsOf 412 patients enrolled into the REST trial, 391 (95%) had 2-year mortality outcome data available. There was no difference in the time to death between intervention and standard care (HR 1.08 (0.81, 1.44); log-rank test p=0.61). 161 patients alive at 1 year provided at least one questionnaire response. There was no difference in respiratory function, post-traumatic stress disorder, cognitive dysfunction or health-related quality of life between patients allocated to intervention or standard care.ConclusionLower-tidal volume ventilation facilitated by vv-ECCO2R does not affect 1-year mortality in patients with moderate-to-severe AHRF. Of the patients who provided questionnaire responses, there was no treatment effect on long-term respiratory function, post-traumatic stress disorder, cognitive dysfunction or health-related quality of life.Trial registration numberClinicalTrials.gov identifier: NCT02654327.

Is It Time to Put Low-Flow Extracorporeal Carbon Dioxide Removal to REST?*

“…The results did not demonstrate any short-term benefit with ECCO 2 R. Similarly, a prespecified analysis failed to demonstrate any survival benefit at 1 year (11). Furthermore, there was no treatment effect on long-term respiratory function, posttraumatic stress disorder, cognitive dysfunction, or health-related quality of life (11). Although experience to date suggests that low-flow ECCO 2 R is both feasible and capable of supporting reductions in Vt and driving pressure in moderate ARDS (12), the benefits of doing so have not been established.…”

“…The trial was discontinued by the data monitoring and ethics committee prior to the recruitment of the planned sample size due to an excess of adverse events in the ECCO 2 R group. The results did not demonstrate any short-term benefit with ECCO 2 R. Similarly, a prespecified analysis failed to demonstrate any survival benefit at 1 year (11). Furthermore, there was no treatment effect on long-term respiratory function, posttraumatic stress disorder, cognitive dysfunction, or health-related quality of life (11).…”