Randomized Clinical Trial of Pressure-Controlled Inverse Ratio Ventilation and Extracorporeal CO2 Removal for Adult Respiratory Distress Syndrome

Morris, Alan H.; Wallace, C. J.; Menlove, Ronald L.; Clemmer, Terry P.; Orme, James F.; Weaver, Lindell K.; Dean, Nathan C.; Thomas, Frank; East, Thomas D.; Pace, Nathan L.; Suchyta, Mary R.; Beck, Eduardo; Bombino, Michela; Sittig, Dean F.; Bohm, Stephen; Hoffmann, Barbara; Becks, Hayo; Butler, S. L.; Pearl, James; Rasmusson, B.Y.

doi:10.1097/00132586-199504000-00017

Cited by 231 publications

(358 citation statements)

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“…Ten studies fulfilled the inclusion criteria, including four RCTs (19)(20)(21)(22) and six observational studies (14,(23)(24)(25)(26)(27). No SYSTEMATIC REVIEW SYSTEMATIC REVIEW pediatric trials met the inclusion criteria, and, therefore, only adult patients were included in all analyses.…”

Section: Literature Searchmentioning

confidence: 99%

Extracorporeal Life Support for Acute Respiratory Failure. A Systematic Review and Metaanalysis

et al. 2014

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Rationale: Extracorporeal life support (ECLS) for acute respiratory failure has increased as a result of technological advancements and promising results from recent studies as compared with historical trials.Objectives: Systematically review the effect of ECLS compared with mechanical ventilation on mortality, length of stay, and adverse events in respiratory failure.Methods: Data sources included were MEDLINE, EMBASE, and CENTRAL (through to October 2013). Any randomized controlled trial (RCT) or observational study comparing ECLS to mechanical ventilation in adults was used. Two authors independently abstracted the data. Our primary outcome was mortality. Secondary outcomes included intensive care unit length of stay, hospital length of stay, and adverse events. A sensitivity analysis was performed restricted to RCTs and quasi-RCTs, and a number of predefined subgroups were identified to explore heterogeneity. Measurements and Main Results:Ten studies (four RCTs, six observational studies, 1,248 patients) were included. There was no significant difference in hospital mortality with ECLS as compared with mechanical ventilation (risk ratio [RR], 1.02; 95% confidence interval [CI], 0.79-1.33; I 2 = 77%). When restricted to venovenous ECLS studies of randomized trials and quasi-randomized trials (three studies; 504 patients), there was a decrease in mortality with ECLS compared with mechanical ventilation (RR, 0.64; 95% CI, 0.51-0.79; I 2 = 15%). There were insufficient study-level data to evaluate most secondary outcomes. Bleeding was significantly greater in the ECLS group (RR, 11.44; 95% CI, 3.11-42.06; I 2 = 0%). In the H1N1 subgroup (three studies; 364 patients), ECLS was associated with significantly lower hospital mortality (RR, 0.62; 95% CI, 0.45-0.8; I 2 = 25%).Conclusions: ECLS was not associated with a mortality benefit in patients with acute respiratory failure. However, a significant mortality benefit was seen when restricted to higher-quality studies of venovenous ECLS. Patients with H1N1-acute respiratory distress syndrome represent a subgroup that may benefit from ECLS. Future studies are needed to confirm the efficacy of ECLS as well as the optimal configuration, indications, and timing for adult patients with respiratory failure.

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Section: Literature Searchmentioning

confidence: 99%

Extracorporeal Life Support for Acute Respiratory Failure. A Systematic Review and Metaanalysis

et al. 2014

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“…In the same years, Gattinoni and Kolobow proposed to exploit ECMO to decrease respiratory rate, tidal volume, and airway pressure favoring lung healing (low frequency positive pressure ventilation, LFPPV; [7]). In 1994, however, the negative results of a second randomized clinical trial on the topic where published [21]. As a consequence, only few centers continued to provide veno-venous ECMO as a last resource in selected patients with respiratory failure.…”

Section: Historical Backgroundmentioning

confidence: 99%

Ventilation during extracorporeal support

Pesenti

Carlesso

Länger

et al. 2017

Med Klin Intensivmed Notfmed

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“…This is because of increased cost and logistics but also because of disappointing results from the two previous randomized trials. 4,5 There has been renewed interest in adult ECMO due to encouraging results from case series, 6,7 improved ECMO technology, 2 general advances in critical care, 3,8 and, most recently, the use of ECMO in H1N1 patients. 9,10 In fact, CESAR was published electronically in the same month period as a retrospective case review of ECMO in adult respiratory failure 11 and a meta-analysis of ECMO following adult cardiac arrest.…”

Section: Critical Appraisalmentioning

confidence: 99%

“…This is because of increased cost and logistics but also because of disappointing results from the two previous randomized trials. 4,5 …”

mentioning

confidence: 99%

Extracorporeal membrane oxygenation (ECMO) in severe adult respiratory distress syndrome

Brindley

Cave

Lequier

2010

Can J Anesth/J Can Anesth

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Article assessedPeek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009; 374: 1351-63. Critical care issueSevere adult respiratory distress syndrome (ARDS) remains associated with high mortality despite improved ventilatory techniques. While extracorporeal membrane oxygenation (ECMO) is not uncommon in neonatal/pediatric critical care, studies had yet to show similar benefits in adults. Therefore, the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) Trial by Peek et al. 1 was eagerly anticipated. It was the first randomized study of ECMO in adult patients in over 15 yr and the largest ever concerning this condition. 2 Summary and key findingsIn this multicentre randomized control trial from the United Kingdom, 180 patients, aged 18-65 yr, were analyzed. The patients had severe but potentially reversible respiratory failure, a Murray Score of C 3.0 (determined by combining PaO 2 /F I 0 2 ratio, positive end expiratory pressure level, lung compliance, chest radiograph appearance, and F I 0 2 of 1.0), or uncompensated hypercapnea (pH \ 7.2) despite conventional treatment. They were randomized 1:1 to conventional management without transfer vs transfer to one site and consideration of ECMO. A greater proportion of patients randomized to consideration of ECMO were alive at six months compared with patients randomized to conventional management (63% or 57/90 vs 50% or 45/90, respectively). This outcome did not reach statistical significance (relative risk 0.73; 95% confidence interval [CI] [0.52-1.03]; P = 0.07). However, a significantly greater percentage of patients randomized to consideration of ECMO survived to six months without severe disability compared with patients randomized to conventional management (63% [57/90] vs 47% [41/87], respectively; relative risk 0.69; 95% CI [0.05-0.97]; P = 0.03). Referral for ECMO consideration was associated with 0.03 quality-adjusted years (QALYS) at six months. The cost per QALY for ECMO was 19,252 pounds sterling (GBP) (95% CI [7,200]). Despite conventional management, the authors concluded that it was appropriate to transfer adults with severe ARDS to a centre with an ECMO-based management protocol. Critical appraisalCurrent state of the literature and study relevance Extra corporeal membrane oxygenation is accepted as a standard-of-care for neonates and children with progressive respiratory and/or cardiac failure refractory to conventional management. [1][2][3] In contrast, adult ECMO is currently confined to a few specialized centres and reserved for exceptional cases. This is because of increased cost and logistics but also because of disappointing results from the two previous randomized trials. 4,5

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Randomized Clinical Trial of Pressure-Controlled Inverse Ratio Ventilation and Extracorporeal CO2 Removal for Adult Respiratory Distress Syndrome

Cited by 231 publications

References 0 publications

Extracorporeal Life Support for Acute Respiratory Failure. A Systematic Review and Metaanalysis

Extracorporeal Life Support for Acute Respiratory Failure. A Systematic Review and Metaanalysis

Ventilation during extracorporeal support

Extracorporeal membrane oxygenation (ECMO) in severe adult respiratory distress syndrome

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