Influence of immunosuppression in patients with severe acute respiratory distress syndrome on veno‐venous extracorporeal membrane oxygenation therapy

Abstract

Prognosis of patients suffering from acute respiratory distress syndrome (ARDS) is poor. This is especially true for immunosuppressed patients. It is controverisal whether these patients should receive veno‐venous extracorporeal membrane oxygenation (VV ECMO) while evidence on this topic is sparse. We report retrospective data of a single‐center registry of patients with severe ARDS requiring ECMO support between October 2010 and June 2019. Patients were analyzed by their status of immunosuppression. ECMO weaning success and hospital survival were analyzed before and after propensity score matching (PSM). Moreover, ventilator free days (VFD) were compared. A total of 288 patients were analyzed (age 55 years, 67% male), 88 (31%) presented with immunosuppression. Survival rates were lower in immunosuppressed patients (27% vs. 53%, P < .001 and 27% vs. 48% after PSM, P = .006). VFD (60 days) were lower for patients with immunosuppression (11.9 vs. 22.4, P < .001), and immunosuppression was an independent predictor for mortality in multivariate analysis. Hospital survival was 20%, 14%, 35%, and 46% for patients with oncological malignancies, solid organ transplantation, autoimmune diseases, and HIV, respectively. In this analysis immunosuppression was an independent predictor for mortality. However, there were major differences in the weaning and survival rates between the etiologies of immunosuppression which should be considered in decision making.

Carboxyhemoglobin (CO-Hb) Correlates with Hemolysis and Hospital Mortality in Extracorporeal Membrane Oxygenation: A Retrospective Registry

“…ECPR was defined as VA ECMO cannulation during continuous cardiopulmonary resuscitation without return of spontaneous circulation (ROSC); or as VA ECMO cannulation within the first 20 min after ROSC in case of persistent hemodynamic instability as previously suggested [ 25 ]. ECMO cannulation and operation were done according to regularly revised standard operating procedures as described earlier [ 26 , 27 ].…”

Extracorporeal Life Support for Patients With Newly Diagnosed HIV and Acute Respiratory Distress Syndrome: A Systematic Review and Analysis of Individual Patient Data

“…24 Rilinger et al . 25 reported a comparable survival of HIV patients (46%) to patients without immunodeficiency, and a markedly higher survival when compared to other immunodeficiency etiologies. Finally, PJ infections are typically associated with a very high mortality.…”

“…Moreover, the lower mortality of HIV positive compared to non-HIV immunocompromised patients may be explained by the underlying disease itself, often characterized by a fulminant disease progression, severe refractory hypoxia, and a higher incidence of shock in the later ones. 24 Rilinger et al 25 reported a comparable survival of HIV patients (46%) to patients without immunodeficiency, and a markedly higher survival when compared to other immunodeficiency etiologies. Finally, PJ infections are typically associated with a very high mortality.…”

“…26 Given the above, and until further evidence is available, ECMO support should not be withheld in newly diagnosed HIV patients with ARDS. 25,26 The most often reported adverse event includes pneumothorax. The clinical course of PJ pneumonia may be complicated by its occurrence (up to 20% in non-HIV patients 27 ), influencing oxygenation, requiring surgical interventions or mechanical ventilation.…”

Awake Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Which Clinical Issues Should Be Taken Into Consideration

“…As reflected in predictive survival models of ARDS (25,(30)(31)(32), immunosuppression independently predicts worse outcomes, with even higher mortality in patients supported by ECMO. A recent retrospective study involving a total of 288 severe ARDS patients requiring ECMO support showed that immunosuppressed ones had both lower survival rates and ventilator-free days (33) despite the diverse survival rate among the different etiologies of immunosuppression. However, it is interesting that immunocompromised ARDS patients are more likely to be selected for awake ECMO (13,18), and the possible reasons might be as follows: (1) The immunocompromised state in these patients mainly results from HIV infection, hematological malignancies, the transplantation of solid organs, and autoimmune diseases treated with corticoids and/or immunosuppressive therapy (13,18,32).…”