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.
Bibliographical noteFunding Information:
The study was supported by the Direction de la Recherche Clinique et de l’Innovation (DRCI), Assistance Publique—Hopitaux de Paris (APHP), with a grant from the French Ministry of Health (CRC 2018, #18,021).
The EOLIA trial was supported by the Direction de la Recherche Clinique et du Développement (DRCD), Assistance Publique–Hôpitaux de Paris (APHP), with a grant from the French Ministry of Health (Programme Hospitalier de Recherche Clinique number, PHRC 2009 081,224), the EOLIA Trial Group, the Réseau Européen en Ventilation Artificielle (REVA) and the International ECMO Network (ECMONet, https://www.internationalecmonetwork.org ).
The CESAR trial was supported by the UK NHS Health Technology Assessment, English National Specialist Commissioning Advisory Group, Scottish Department of Health, and Welsh Department of Health.
Alain Combes reports grants from Getinge, personal fees from Getinge, Baxter and Xenios outside the submitted work. Matthieu Schmidt reports lecture fees from Getinge, Drager and Xenios outside the submitted work. The other authors declare that they have no conflicts of interest related to the purpose of this manuscript. The study protocol for the systematic review and IPD meta-analysis was approved by the relevant independent ethics committees: in France, Comité de Protection des Personnes CPP Ile de France VI, Pitié-Salpêtrière, on 04/19/2018, Ref #12 and in the UK by the Ethics committee of the London School of Hygiene and Tropical Medicine, on 04/12/2019, LSHTM Ethics Ref: 17159. Only patient characteristics and outcomes already evaluated in the trials were combined in this systematic review and meta-analysis.
© 2020, Springer-Verlag GmbH Germany, part of Springer Nature.
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- Acute respiratory distress syndrome
- Adult patients
- Extracorporeal membrane oxygenation
- Individual patient data meta-analysis
ASJC Scopus subject areas
- Critical Care and Intensive Care Medicine