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Meta-Analysis
. 2020 Nov;46(11):2048-2057.
doi: 10.1007/s00134-020-06248-3. Epub 2020 Oct 6.

ECMO for severe ARDS: systematic review and individual patient data meta-analysis

Alain Combes  1   2 , Giles J Peek  3 , David Hajage  4 , Pollyanna Hardy  5 , Darryl Abrams  6   7 , Matthieu Schmidt  8   9 , Agnès Dechartres  4 , Diana Elbourne  10
Affiliations
Meta-Analysis

ECMO for severe ARDS: systematic review and individual patient data meta-analysis

Alain Combes et al. Intensive Care Med. 2020 Nov.

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: Acute respiratory distress syndrome; Adult patients; Extracorporeal membrane oxygenation; Individual patient data meta-analysis.

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Conflict of interest statement

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.

Figures

Fig. 1
Fig. 1
Forest plot of 90-day mortality in the intention-to-treat population
Fig. 2
Fig. 2
Kaplan–Meier survival estimates in the intention-to-treat population of the time to death within the first 90 study days
Fig. 3
Fig. 3
Subgroup analyses for the primary outcome according to baseline characteristics. MV, mechanical ventilation; number of organ failed (0–6) defined as the corresponding component sequential organ failure assessment (SOFA) score > 2; APACHE2 (CESAR) and SAPS2 (EOLIA) scores were both translated to predicted probability of ICU mortality
See this image and copyright information in PMC

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