ECMO for severe ARDS: systematic review and individual patient data meta-analysis
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ORIGINAL
ECMO for severe ARDS: systematic review and individual patient data meta‑analysis Alain Combes1,2* , Giles J. Peek3, David Hajage4, Pollyanna Hardy5, Darryl Abrams6,7, Matthieu Schmidt1,2, Agnès Dechartres4 and Diana Elbourne8 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Abstract Purpose: To assess the effect of venovenous extracorporeal membrane oxygenation (ECMO) compared to conventional management in patients with severe acute respiratory distress syndrome (ARDS). Methods: We conducted a systematic review and individual patient data meta-analysis of randomised controlled trials (RCTs) performed after Jan 1, 2000 comparing ECMO to conventional management in patients with severe ARDS. The primary outcome was 90-day mortality. Primary analysis was by intent-to-treat. Results: We identified two RCTs (CESAR and EOLIA) and combined data from 429 patients. On day 90, 77 of the 214 (36%) ECMO-group and 103 of the 215 (48%) control group patients had died (relative risk (RR), 0.75, 95% confidence interval (CI) 0.6–0.94; P = 0.013; I2 = 0%). In the per-protocol and as-treated analyses the RRs were 0.75 (95% CI 0.6–0.94) and 0.86 (95% CI 0.68–1.09), respectively. Rescue ECMO was used for 36 (17%) of the 215 control patients (35 in EOLIA and 1 in CESAR). The RR of 90-day treatment failure, defined as death for the ECMO-group and death or crossover to ECMO for the control group was 0.65 (95% CI 0.52–0.8; I2 = 0%). Patients randomised to ECMO had more days alive out of the ICU and without respiratory, cardiovascular, renal and neurological failure. The only significant treatment-covariate interaction in subgroups was lower mortality with ECMO in patients with two or less organs failing at randomization. Conclusions: In this meta-analysis of individual patient data in severe ARDS, 90-day mortality was significantly lowered by ECMO compared with conventional management. Keywords: Extracorporeal membrane oxygenation, Acute respiratory distress syndrome, Adult patients, Individual patient data meta-analysis Introduction
*Correspondence: [email protected] 1 Sorbonne Université, INSERM, UMRS_1166‑ICAN, Institute of Cardiometabolism and Nutrition, 75013 Paris, France Full author information is available at the end of the article
Ventilatory management of patients with severe acute respiratory distress syndrome (ARDS) has improved over the last decades with a strategy combining low tidal volume (VT) ventilation [1], high positive end-expiratory pressure (PEEP) [2, 3], neuromuscular blocking agents [4] and prone positioning [5]. However, ventilator-induced lung injury (VILI) may persist in these patients since a recent and large epidemiological study showed that their hospital mortality was still 46% [6]. Recently, even higher mortality was reported for patients with severe acute
respiratory syndrome coronavirus2 (SARS-CoV-2) infection who needed invasive mechanical ventilation [7–9]. Venovenous extracorporeal membrane oxygenation (ECMO) providing full blood oxygenation, C O2 elimination and
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