ECMO for ARDS: mortality benefit seen in meta-analysis

  • Lancet Resp Med

  • curated by Jenny Blair, MD
  • Clinical Essentials
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Takeaway

  • Extracorporeal membrane oxygenation (ECMO) emerged as beneficial in severe acute respiratory distress syndrome (ARDS) in this meta-analysis of the 2 existing randomized controlled trials (RCTs).
  • Editorial : 
    • "ECMO is indicated in patients with ARDS when other proven and less invasive strategies have been tried unsuccessfully."
    • Calls for "improve[d] adoption of proven therapies," such as prone positioning.

Why this matters

  • EOLIA was stopped early despite trend toward benefit, with some experts criticizing expected effect size.
  • In CESAR, not all ECMO patients actually underwent ECMO.
  • Further RCTs of ECMO for ARDS are unlikely.

Key results

  • ECMO vs controls:
    • Mortality in 2 RCTs:
      • 34% (73/214) vs 47% (101/215);
      • Risk ratio (RR): 0.73 (95% CI, 0.58-0.92; P=.008);
      • Moderate-certainty evidence.
    • Treatment failure in 2 RCTs:
      • 36% (77/214) vs 64% (138/214);
      • RR: 0.58 (95% CI, 0.39-0.84; P=.004);
      • High-certainty evidence.
    • 30-day mortality in 2 RCTs plus 3 observational trials:
      • 31% (120/386) vs 45% (176/387);
      • RR, 0.69 (95% CI, 0.50-0.95; P=.02);
      • Moderate-certainty evidence.
  • ECMO: fewer ischemic strokes, more major hemorrhages.
  • Groups had similar hemorrhagic stroke rates.

Study design

  • Systematic review, meta-analysis, 5 studies: 2 RCTs (n=429) and 3 observational studies (n=626).
  • Outcome: 60-day mortality in RCTs.
  • Funding: None.

Limitations

  • Venoarterial ECMO not assessed.
  • High-volume centers.

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