Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Observational Study
. 2022 May 4:377:e068723.
doi: 10.1136/bmj-2021-068723.

Venovenous extracorporeal membrane oxygenation in patients with acute covid-19 associated respiratory failure: comparative effectiveness study

Martin Urner  1   2   3 , Adrian G Barnett  4 , Gianluigi Li Bassi  5   6   7   8   9 , Daniel Brodie  10   11 , Heidi J Dalton  12   13 , Niall D Ferguson  1   2   3   14   15   16 , Silver Heinsar  5   6   8   17 , Carol L Hodgson  18   19 , Giles Peek  20 , Kiran Shekar  5   6   9 , Jacky Y Suen  5   6 , John F Fraser  5   6   8 , Eddy Fan  21   2   3   14   16 ; COVID-19 Critical Care Consortium Investigators
Collaborators, Affiliations
Observational Study

Venovenous extracorporeal membrane oxygenation in patients with acute covid-19 associated respiratory failure: comparative effectiveness study

Martin Urner et al. BMJ. .

Abstract

Objective: To estimate the effect of extracorporeal membrane oxygenation (ECMO) compared with conventional mechanical ventilation on outcomes of patients with covid-19 associated respiratory failure.

Design: Observational study.

Setting: 30 countries across five continents, 3 January 2020 to 29 August 2021.

Participants: 7345 adults admitted to the intensive care unit with clinically suspected or laboratory confirmed SARS-CoV-2 infection.

Interventions: ECMO in patients with a partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) ratio <80 mm Hg compared with conventional mechanical ventilation without ECMO.

Main outcome measure: The primary outcome was hospital mortality within 60 days of admission to the intensive care unit. Adherence adjusted estimates were calculated using marginal structural models with inverse probability weighting, accounting for competing events and for baseline and time varying confounding.

Results: 844 of 7345 eligible patients (11.5%) received ECMO at any time point during follow-up. Adherence adjusted mortality was 26.0% (95% confidence interval 24.5% to 27.5%) for a treatment strategy that included ECMO if the PaO2/FiO2 ratio decreased <80 mm Hg compared with 33.2% (31.8% to 34.6%) had patients received conventional treatment without ECMO (risk difference -7.1%, 95% confidence interval -8.2% to -6.1%; risk ratio 0.78, 95% confidence interval 0.75 to 0.82). In secondary analyses, ECMO was most effective in patients aged <65 years and with a PaO2/FiO2 <80 mm Hg or with driving pressures >15 cmH2O during the first 10 days of mechanical ventilation.

Conclusions: ECMO was associated with a reduction in mortality in selected adults with covid-19 associated respiratory failure. Age, severity of hypoxaemia, and duration and intensity of mechanical ventilation were found to be modifiers of treatment effectiveness and should be considered when deciding to initiate ECMO in patients with covid-19.

PubMed Disclaimer

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/coi_dischlosure.pdf. MU is supported by a Vanier Canada graduate scholarship from the Canadian Institutes of Health Research. AGB is supported by a National Health and Medical Research Council fellowship. SH is supported by a PhD scholarship from the Prince Charles Hospital Foundation. EF reports personal fees from ALung Technologies, Aerogen, Baxter, Boehringer-Ingelheim, GE Healthcare, Inspira, and Vasomune outside the submitted work; he is the chair of the research committee, Extracorporeal Life Support Organization (ELSO) and chair of the data committee, International ECMO Network (ECMONet). DB receives research support from ALung Technologies. He reports personal fees from Abiomed, Medtronic, Inspira, Cellenkos, and Xenios; he is the president-elect of ELSO and chair of the executive committee of ECMONet. GLB is a recipient of the Biomedicine international training research programme for excellent clinician-scientists (BITRECS) fellowship; the BITRECS project has received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie (grant agreement No 754550) and from the La Caixa Foundation (ID 100010434), under agreement LCF/PR/GN18/50310006. JFF reports grant support from Fisher and Paykel Healthcare, Xenios, Getinge, Cynata, CSL Behring (Australia), and Queensland Health outside the submitted work. CLH is supported by a National Health and Medical Research Council investigator grant from Australia. KS acknowledges research support from Metro North Hospital and Health Service. JYS is supported by the Advance Queensland Fellowship from the Queensland government.

Figures

Fig 1
Fig 1
Treatment with extracorporeal membrane oxygenation (ECMO) if ratio of partial pressure of arterial oxygen to fraction of inspiratory oxygen (PaO2/FiO2) was <80 mm Hg, was compared with treatment with conventional mechanical ventilation without ECMO. Adherence adjusted estimates are reported for differences in hospital mortality and probability of hospital discharge alive in 7345 patients with covid-19 associated acute respiratory failure. Shaded areas represent 95% confidence intervals
Fig 2
Fig 2
As treated analysis in 7345 patients, with hospital mortality compared between treatment as received, which could have included treatment with extracorporeal membrane oxygenation (ECMO), and treatment with conventional mechanical ventilation without ECMO. Shaded areas represent 95% confidence intervals
Fig 3
Fig 3
Treatment with extracorporeal membrane oxygenation (ECMO) if ratio of partial pressure of arterial oxygen to fraction of inspiratory oxygen (PaO2/FiO2) was <80 mm Hg compared with conventional mechanical ventilation without ECMO. Adherence adjusted effects (95% confidence intervals) on hospital mortality within 60 days reported by age groups and baseline comorbidities
Fig 4
Fig 4
Treatment with extracorporeal membrane oxygenation (ECMO) if ratio of partial pressure of arterial oxygen to fraction of inspiratory oxygen (PaO2/FiO2) was <80 mm Hg compared with conventional mechanical ventilation without ECMO. The influence of duration of mechanical ventilation preceding ECMO is illustrated using risk ratios with 95% confidence intervals. Dots represent a loess curve
Fig 5
Fig 5
Treatment with extracorporeal membrane oxygenation (ECMO) if ratio of partial pressure of arterial oxygen to fraction of inspiratory oxygen (PaO2/FiO2) was <80 mm Hg compared with conventional mechanical ventilation without ECMO. The primary analysis was repeated with different PaO2/FiO2 ratio thresholds for initiation of ECMO. Shaded areas represent 95% confidence intervals
Fig 6
Fig 6
Treatment with extracorporeal membrane oxygenation (ECMO) if ratio of partial pressure of arterial oxygen to fraction of inspiratory oxygen (PaO2/FiO2) was <80 mm Hg compared with conventional mechanical ventilation without ECMO. Treatment strategies, when ECMO was initiated based on various thresholds for driving pressure, were compared with conventional mechanical ventilation. Shaded areas represent 95% confidence intervals
See this image and copyright information in PMC

Comment in

References

    1. Wu C, Chen X, Cai Y, et al. . Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med 2020;180:934-43. 10.1001/jamainternmed.2020.0994. - DOI - PMC - PubMed
    1. Li X, Guo Z, Li B, et al. . Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019 in Shanghai, China. ASAIO J 2020;66:475-81. 10.1097/MAT.0000000000001172. - DOI - PMC - PubMed
    1. Combes A, Hajage D, Capellier G, et al. EOLIA Trial Group, REVA, and ECMONet . Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med 2018;378:1965-75. 10.1056/NEJMoa1800385. - DOI - PubMed
    1. Bartlett RH, Ogino MT, Brodie D, et al. . Initial ELSO Guidance Document: ECMO for COVID-19 Patients with Severe Cardiopulmonary Failure. ASAIO J 2020;66:472-4. 10.1097/MAT.0000000000001173. - DOI - PMC - PubMed
    1. Peek GJ, Mugford M, Tiruvoipati R, et al. CESAR trial collaboration . 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. 10.1016/S0140-6736(09)61069-2. - DOI - PubMed

Publication types