Venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis
Laveena Munshi, Allan Walkey, Ewan Goligher, et al
Lancet Respir Med 2019; 7: 163-172
Background 背景
Use of extracorporeal membrane oxygenation (ECMO) in adults with severe acute respiratory distress syndrome has increased in the past 10 years. However, the efficacy of venovenous ECMO in people with acute respiratory distress syndrome is uncertain according to the most recent data. We aimed to estimate the effect of venovenous ECMO on mortality from acute respiratory distress syndrome.
过去10年间，成年重症ARDS患者使用ECMO逐渐增多。然而，近期数据显示，VV-ECMO对于ARDS患者的疗效并不确定。我们旨在评价VV-ECMO对ARDS患者病死率的影响。
Methods 方法
In this systematic review and meta-analysis, we searched MEDLINE (including MEDLINE In-Process and Epub Ahead of Print), Embase and the Wiley search platform in the Cochrane database for randomised controlled trials and observational studies with matching of conventional mechanical ventilation with and without venovenous ECMO in adults with acute respiratory distress syndrome. Titles, abstracts, and full-text articles were screened in duplicate by two investigators. Data for study design, patient characteristics, interventions, and study outcomes were abstracted independently and in duplicate. Studies were weighted with the inverse variance method and data were pooled via random-effects modelling. We calculated risk ratios (RRs) and 95% CIs to summarise results. The primary outcome was 60-day mortality across randomised controlled trials. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines were used to rate the quality of evidence.
在这项系统回顾和meta分析中，我们对MEDLINE，Embase及Cochrane数据库的Wiley检索平台进行了检索，检索匹配传统机械通气+/- VV-ECMO用于成人ARDs患者的随机对照试验及观察性研究。两名研究者分别筛选研究题目、摘要几全文，并分别独立提取试验设计、患者特征、干预措施及研究预后等数据。采用逆方差加权及随机效应模型整合数据。我们计算综合结果的风险比(RRs)及95%CI。主要预后指标为随机对照试验的60天病死率。采用GRADE指南评估证据质量。
Findings 结果
We included five studies, two randomised controlled trials and three observational studies with matching techniques (total N=773 patients). In the primary analysis, which included two randomised controlled trials with a total population of 429 patients, 60-day mortality was significantly lower in the venovenous ECMO group than in the control group (73 [34%] of 214 vs 101 [47%] of 215; RR 0·73 [95% CI 0·58–0·92]; p=0·008; I 2 0%). The GRADE level of evidence for this outcome was moderate. Three studies included data for the incidence of major haemorrhage in the ECMO group. 48 (19%) of the 251 patients in these three studies had major haemorrhages.
我们纳入了5项研究，包括2项随机对照试验及3项观察性研究（共有773名患者）。主要分析包括了2项随机对照试验的429名患者，VV-ECMO组60天病死率显著低于对照组(73/214 [34%] vs 101/215 [47%]; RR 0·73 [95% CI 0·58–0·92]; p=0·008; I 2 0%)。60天病死率的证据GRADE分级为中度。3项研究纳入ECMO组大出血发生率的数据。3项研究共251名患者中的48名(19%)发生了的大出血。
Interpretation 结论
Compared with conventional mechanical ventilation, use of venovenous ECMO in adults with severe acute respiratory distress syndrome was associated with reduced 60-day mortality. However, venovenous ECMO was also associated with a moderate risk of major bleeding. These findings have important implications surrounding decision making for management of severe acute respiratory distress syndrome at centres providing venovenous ECMO.
与传统机械通气相比，重症ARDS成年患者使用VV-ECMO伴随60天病死率降低。然而，VV-ECMO还伴随大出血的中度风险。这些结果对各个中心使用VV-ECMO治疗重度ARDS患者的决策有重要意义。
Funding
None.
