ECMO for severe ARDS: systematic review and individual patient data meta-analysis

Combes, Alain; Peek, Giles J.; Hajage, David; Hardy, Pollyanna; Abrams, Darryl; Schmidt, Matthieu; Dechartres, Agnès; Elbourne, Diana

doi:10.1007/s00134-020-06248-3

Cited by 236 publications

(237 citation statements)

References 50 publications

(68 reference statements)

Supporting

Mentioning

211

Contrasting

Unclassified

Order By: Relevance

“…ECMO has been used for decades in the treatment of severe ARDS of various etiologies. Recent clinical trials evaluated the efficacy and safety of ECMO in severe ARDS [ 6 , 7 ], with a survival benefit demonstrated in a meta-analysis [ 8 ].…”

Section: Introductionmentioning

confidence: 99%

Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19

Brenner²,

et al. 2021

View full text Add to dashboard Cite

Purpose Limited data are available on venovenous extracorporeal membrane oxygenation (ECMO) in patients with severe hypoxemic respiratory failure from coronavirus disease 2019 (COVID-19). Methods We examined the clinical features and outcomes of 190 patients treated with ECMO within 14 days of ICU admission, using data from a multicenter cohort study of 5122 critically ill adults with COVID-19 admitted to 68 hospitals across the United States. To estimate the effect of ECMO on mortality, we emulated a target trial of ECMO receipt versus no ECMO receipt within 7 days of ICU admission among mechanically ventilated patients with severe hypoxemia (PaO 2 /FiO 2 < 100). Patients were followed until hospital discharge, death, or a minimum of 60 days. We adjusted for confounding using a multivariable Cox model. Results Among the 190 patients treated with ECMO, the median age was 49 years (IQR 41–58), 137 (72.1%) were men, and the median PaO 2 /FiO 2 prior to ECMO initiation was 72 (IQR 61–90). At 60 days, 63 patients (33.2%) had died, 94 (49.5%) were discharged, and 33 (17.4%) remained hospitalized. Among the 1297 patients eligible for the target trial emulation, 45 of the 130 (34.6%) who received ECMO died, and 553 of the 1167 (47.4%) who did not receive ECMO died. In the primary analysis, patients who received ECMO had lower mortality than those who did not (HR 0.55; 95% CI 0.41–0.74). Results were similar in a secondary analysis limited to patients with PaO 2 /FiO 2 < 80 (HR 0.55; 95% CI 0.40–0.77). Conclusion In select patients with severe respiratory failure from COVID-19, ECMO may reduce mortality. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-020-06331-9.

show abstract

Section: Introductionmentioning

confidence: 99%

Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19

Brenner²,

et al. 2021

View full text Add to dashboard Cite

show abstract

“…In the primary outcome of 60-day mortality, the use of V-V ECMO was associated with the better outcome compared with the use of conventional mechanical ventilation (34% vs 47%; RR, 0.73; 95%CI, 0.58–0.92; p = 0.008). Combes et al [ 66 ] further collected individual patient data and conducted a meta-analysis of RCTs. Seventy-seven (36%) of the ECMO group and 103 (48%) of the control group had died on day 90.…”

Section: Ecmomentioning

confidence: 99%

Oxygen administration for patients with ARDS

Ohshimo

2021

j intensive care

View full text Add to dashboard Cite

Acute respiratory distress syndrome (ARDS) is a fatal condition with insufficiently clarified etiology. Supportive care for severe hypoxemia remains the mainstay of essential interventions for ARDS. In recent years, adequate ventilation to prevent ventilator-induced lung injury (VILI) and patient self-inflicted lung injury (P-SILI) as well as lung-protective mechanical ventilation has an increasing attention in ARDS.Ventilation-perfusion mismatch may augment severe hypoxemia and inspiratory drive and consequently induce P-SILI. Respiratory drive and effort must also be carefully monitored to prevent P-SILI. Airway occlusion pressure (P0.1) and airway pressure deflection during an end-expiratory airway occlusion (Pocc) could be easy indicators to evaluate the respiratory drive and effort. Patient-ventilator dyssynchrony is a time mismatching between patient’s effort and ventilator drive. Although it is frequently unrecognized, dyssynchrony can be associated with poor clinical outcomes. Dyssynchrony includes trigger asynchrony, cycling asynchrony, and flow delivery mismatch. Ventilator-induced diaphragm dysfunction (VIDD) is a form of iatrogenic injury from inadequate use of mechanical ventilation. Excessive spontaneous breathing can lead to P-SILI, while excessive rest can lead to VIDD. Optimal balance between these two manifestations is probably associated with the etiology and severity of the underlying pulmonary disease.High-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NPPV) are non-invasive techniques for supporting hypoxemia. While they are beneficial as respiratory supports in mild ARDS, there can be a risk of delaying needed intubation. Mechanical ventilation and ECMO are applied for more severe ARDS. However, as with HFNC/NPPV, inappropriate assessment of breathing workload potentially has a risk of delaying the timing of shifting from ventilator to ECMO. Various methods of oxygen administration in ARDS are important. However, it is also important to evaluate whether they adequately reduce the breathing workload and help to improve ARDS.

show abstract

“…The role of ECLS to facilitate ultra-lung protective ventilation is an evolving area, with a recent individualpatient data analysis from CESAR and EOLIA showing that vv-ECMO was most beneficial in patients with only 1 or 2 organ failures and was not as helpful in those with the most severe hypoxemia [90]. This concept has been explored with lower flow extra-corporeal CO2 removal (ECCO 2 R) in pilot studies [91], a single small RCT [92], and is the subject of ongoing RCTs.…”

Section: Evolving Standardsmentioning

confidence: 99%

Current and evolving standards of care for patients with ARDS

et al. 2020

View full text Add to dashboard Cite

Care for patients with acute respiratory distress syndrome (ARDS) has changed considerably over the 50 years since its original description. Indeed, standards of care continue to evolve as does how this clinical entity is defined and how patients are grouped and treated in clinical practice. In this narrative review we discuss current standards-treatments that have a solid evidence base and are well established as targets for usual care-and also evolving standards-treatments that have promise and may become widely adopted in the future. We focus on three broad domains of ventilatory management, ventilation adjuncts, and pharmacotherapy. Current standards for ventilatory management include limitation of tidal volume and airway pressure and standard approaches to setting PEEP, while evolving standards might focus on limitation of driving pressure or mechanical power, individual titration of PEEP, and monitoring efforts during spontaneous breathing. Current standards in ventilation adjuncts include prone positioning in moderate-severe ARDS and veno-venous extracorporeal life support after prone positioning in patients with severe hypoxemia or who are difficult to ventilate. Pharmacotherapy current standards include corticosteroids for patients with ARDS due to COVID-19 and employing a conservative fluid strategy for patients not in shock; evolving standards may include steroids for ARDS not related to COVID-19, or specific biological agents being tested in appropriate subphenotypes of ARDS. While much progress has been made, certainly significant work remains to be done and we look forward to these future developments.

show abstract

ECMO for severe ARDS: systematic review and individual patient data meta-analysis

Cited by 236 publications

References 50 publications

Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19

Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19

Oxygen administration for patients with ARDS

Current and evolving standards of care for patients with ARDS

Contact Info

Product

Resources

About