Venovenous extra-corporeal membrane oxygenation for severe acute respiratory distress syndrome: a matched cohort study

Extracorporeal Membrane Oxygenation (ECMO) Dependent Acute Respiratory Distress Syndrome (ARDS): A Systematic Review and Meta-Analysis

Background: Extracorporeal membrane oxygenation (ECMO) has emerged as a newer method for managing severe acute respiratory distress syndrome (ARDS) and ARDS refractory to conventional management. However, its current role in the management of ARDS is not clear. Therefore, we conducted this meta-analysis to compare the mortality rates of ECMO over conventional management in ARDS.

Methods: PubMed, PubMed Central, Embase, and Scopus were searched using appropriate keywords. We selected studies in adults with ARDS that compared the outcomes of patients treated with ECMO vs. conventional management. Cochrane Risk of Bias (RoB) 2.0 and the JBI (Joanna Briggs Institute) quality assessment tools were used for assessing the risk of bias in RCTs and observational studies, respectively. The I² statistic was used to evaluate heterogeneity, and quantitative synthesis was performed using fixed or random effects to pool studies based on heterogeneities. Meta-analysis was conducted using Revman 5.4.

Result: Twelve studies were included in this meta-analysis. As compared to the conventional management (mechanical ventilation: MV), patients treated with ECMO had lower odds of 30-days mortality (OR, 0.56; 95% CI, 0.37 to 0.84) and 90 days mortality (OR, 0.59; 95% CI, 0.41 to 0.85). However, there was no significant difference between in-hospital mortality (OR, 0.75; 95% CI, 0.40 to 1.41) and intensive care unit (ICU) mortality (OR, 1.00; 95% CI, 0.36 to 2.79). Similarly, length of hospital stays (LOS) (MD, 3.92; 95% CI, -6.26 to 14.11) did not show statistically significant differences across the two groups. However, the average ICU stay (ICU LOS) was 7.28 days longer in the ECMO group compared with the MV group (MD, 7.28; 95% CI, 2.55 to 12.02).

Conclusion: Twenty-eight days and 90-days mortality were decreased in patients managed with ECMO compared with the MV group. Also, ICU LOS was found to be longer in the ECMO group. Furthermore, no statistical difference was found between the two groups for in-hospital mortality and hospital LOS. 

Effect of prone position ventilation on right heart function in patients with acute respiratory distress syndrome

BACKGROUND

Acute respiratory distress syndrome (ARDS) is a severe respiratory disease with a high mortality rate. It is characterized by acute onset of pulmonary edema, hypoxemia, and the need of mechanical ventilation. As the primary treatment, ventilation has been considered effective in treating patients with ARDS. Recently, numerous studies have shown that prone position ventilation demonstrates more efficacy compared with traditional supine position. However, the potential impact of the non-physiological prone position on patients remains unclear. Current study aims to evaluate the effect of prone position ventilation on right heart function in ARDS patients.

METHODS

Following Berlin Diagnostic Criteria, 80 eligible patients were recruited and randomly assigned into prone position ventilation group and supine position ventilation group. Different ventilation methods were implemented in these two groups.

RESULTS

Both positions showed the beneficial effects, as evidenced by decreased PV score and APACHE II score, enhanced blood gas index and right heart function parameters, and the prognosis analysis. However, compared with those receiving SPV treatment, the patients demonstrated greater benefits from PPV treatment, with significant differences in PV score (p < 0.01) and APACHE II score (p < 0.001), blood gas index such as PAPm (p < 0.05), and right heart function indicators (p < 0.05).

CONCLUSION

Prone position mechanical ventilation is more beneficial than supine position ventilation in improving the blood gas status of patients with moderate to severe ARDS, and it is more helpful to reduce the load on the right heart and promote the recovery of patients.

Consenso ECMO colombiano para paciente con falla respiratoria grave asociada a COVID-19

Antecedentes y objetivos

La epidemia de COVID-19 ha creado un desafío sin precedentes en el sistema de salud, generando una demanda creciente. Alrededor del 5% de los pacientes diagnosticados con esta infección requieren ingreso a cuidados intensivos principalmente para soporte ventilatorio con ventilación mecánica por un síndrome de dificultad respiratoria aguda (SDRA) de moderado a grave. Las mortalidades reportadas pueden ser muy altas. Las dos principales causas de muerte en esta infección son la hipoxemia refractaria asociada al SDRA y el shock con insuficiencia orgánica múltiple. La oxigenación con membrana extracorpórea (ECMO) se ha utilizado en pacientes con hipoxemia refractaria sin respuesta a manejo con ventilación mecánica protectora, ventilación en posición prono y relajación muscular. La Organización Mundial de la Salud recomienda considerar ECMO en pacientes adultos y pediátricos con COVID-19 y SDRA refractario, si hay un equipo de expertos disponible.

Métodos

Se utilizó la metodología de consenso formal para generar el Consenso ECMO en la infección SARS-CoV-2 con la mejor evidencia disponible. El desarrollo del consenso combina las técnicas de selección, síntesis, evaluación y gradación de la evidencia: formulación de la pregunta PICO [P - Paciente, Problema o Población. I - Intervención. C - Comparación, control. O - Outcome(s) (muerte)], estrategias de búsqueda sistemática y técnicas de síntesis (metaanálisis).

La evaluación de la calidad de la evidencia y la graduación de la fuerza de las recomendaciones se realizó con la estrategia GRADE, generando al final recomendaciones para los tópicos más relevantes del manejo del paciente con COVID-19 candidato a ECMO y por técnica de consenso formal (Delphi).

Resultados

El consenso colombiano para pacientes con falla respiratoria grave asociada a COVID-19 proporciona un resumen de la evidencia sobre el uso de ECMO en insuficiencia respiratoria hipoxémica aguda grave asociada con la infección SARS-CoV-2, dando recomendaciones sobre sus indicaciones, contraindicaciones, consideraciones y la implementación del grupo ECMOred Colombia.

Conclusiones

El consenso colombiano de ECMO es un documento de guía y consulta para el manejo de pacientes con insuficiencia respiratoria aguda grave refractaria y disfunción cardiovascular asociada con COVID-19 candidatos para ECMO.

Progress of mechanical power in the intensive care unit

Mechanical power of ventilation, currently defined as the energy delivered from the ventilator to the respiratory system over a period of time, has been recognized as a promising indicator to evaluate ventilator-induced lung injury and predict the prognosis of ventilated critically ill patients. Mechanical power can be accurately measured by the geometric method, while simplified equations allow an easy estimation of mechanical power at the bedside. There may exist a safety threshold of mechanical power above which lung injury is inevitable, and the assessment of mechanical power might be helpful to determine whether the extracorporeal respiratory support is needed in patients with acute respiratory distress syndrome. It should be noted that relatively low mechanical power does not exclude the possibility of lung injury. Lung size and inhomogeneity should also be taken into consideration. Problems regarding the safety limits of mechanical power and contribution of each component to lung injury have not been determined yet. Whether mechanical power-directed lung-protective ventilation strategy could improve clinical outcomes also needs further investigation. Therefore, this review discusses the algorithms, clinical relevance, optimization, and future directions of mechanical power in critically ill patients.