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Burrell A, Kim J, Alliegro P, Romero L, Serpa Neto A, Mariajoseph F, Hodgson C. Extracorporeal membrane oxygenation for critically ill adults. Cochrane Database Syst Rev 2023; 9:CD010381. [PMID: 37750499 PMCID: PMC10521169 DOI: 10.1002/14651858.cd010381.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) may provide benefit in certain populations of adults, including those with severe cardiac failure, severe respiratory failure, and cardiac arrest. However, it is also associated with serious short- and long-term complications, and there remains a lack of high-quality evidence to guide practice. Recently several large randomized controlled trials (RCTs) have been published, therefore, we undertook an update of our previous systematic review published in 2014. OBJECTIVES To evaluate whether venovenous (VV), venoarterial (VA), or ECMO cardiopulmonary resuscitation (ECPR) improve mortality compared to conventional cardiopulmonary support in critically ill adults. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was March 2022. The search was limited to English language only. SELECTION CRITERIA We included RCTs, quasi-RCTs, and cluster-RCTs that compared VV ECMO, VA ECMO or ECPR to conventional support in critically ill adults. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was 1. all-cause mortality at day 90 to one year. Our secondary outcomes were 2. length of hospital stay, 3. survival to discharge, 4. disability, 5. adverse outcomes/safety events, 6. health-related quality of life, 7. longer-term health status, and 8. cost-effectiveness. We used GRADE to assess certainty of evidence. MAIN RESULTS Five RCTs met our inclusion criteria, with four new studies being added to the original review (total 757 participants). Two studies were of VV ECMO (429 participants), one VA ECMO (41 participants), and two ECPR (285 participants). Four RCTs had a low risk of bias and one was unclear, and the overall certainty of the results (GRADE score) was moderate, reduced primarily due to indirectness of the study populations and interventions. ECMO was associated with a reduction in 90-day to one-year mortality compared to conventional treatment (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.70 to 0.92; P = 0.002, I2 = 11%). This finding remained stable after performing a sensitivity analysis by removing the single trial with an uncertain risk of bias. Subgroup analyses did not reveal a significant subgroup effect across VV, VA, or ECPR modes (P = 0.73). Four studies reported an increased risk of major hemorrhage with ECMO (RR 3.32, 95% CI 1.90 to 5.82; P < 0.001), while two studies reported no difference in favorable neurologic outcome (RR 2.83, 95% CI 0.36 to 22.42; P = 0.32). Other secondary outcomes were not consistently reported across the studies. AUTHORS' CONCLUSIONS In this updated systematic review, which included four additional RCTs, we found that ECMO was associated with a reduction in day-90 to one-year all-cause mortality, as well as three times increased risk of bleeding. However, the certainty of this result was only low to moderate, limited by a low number of small trials, clinical heterogeneity, and indirectness across studies.
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Affiliation(s)
- Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - Jiwon Kim
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Patricia Alliegro
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lorena Romero
- The Ian Potter Library, The Alfred Hospital, Melbourne, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Intensive Care, Austin Hospital, Melbourne, Australia
| | - Frederick Mariajoseph
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Physiotherapy, The Alfred Hospital, Melbourne, Australia
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Luo X, Lv M, Wang X, Long X, Ren M, Zhang X, Liu Y, Li W, Zhou Q, Ma Y, Fukuoka T, Ahn HS, Lee MS, Luo Z, Liu E, Wang X, Chen Y. Supportive care for patient with respiratory diseases: an umbrella review. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:621. [PMID: 32566558 PMCID: PMC7290632 DOI: 10.21037/atm-20-3298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Supportive treatment is an important and effective part of the management for patients with life-threatening diseases. This study aims to identify and evaluate the forms of supportive care for patients with respiratory diseases. Methods An umbrella review of supportive care for patient with respiratory diseases was undertaken. We comprehensively searched the following databases: Medline, EMBASE, Web of Science, CNKI (China National Knowledge Infrastructure), Wanfang Data and CBM (SinoMed) from their inception to 31 March 2020, and other sources to identify systematic reviews and meta-analyses related to supportive treatments for patient with respiratory diseases including Coronavirus Disease 2019 (COVID-19), severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and influenza. We assessed the methodological quality using the AMSTAR score and the quality of the evidence for the primary outcomes of each included systematic review and meta-analysis. Results We included 18 systematic reviews and meta-analyses in this study. Most studies focused on the respiratory and circulatory support. Ten studies were of high methodological quality, five studies of medium quality, and three studies of low quality. According to four studies extracorporeal membrane oxygenation did not reduce mortality in adults [odds ratio/relative risk (OR/RR) ranging from 0.71 to 1.28], but two studies reported significantly lower mortality in patients receiving venovenous extracorporeal membrane oxygenation than in the control group (OR/RR ranging from 0.38 to 0.73). Besides, monitoring of vital signs and increasing the number of medical staff may also reduce the mortality in patients with respiratory diseases. Conclusions Our overview suggests that supportive care may reduce the mortality of patients with respiratory diseases to some extent. However, the quality of evidence for the primary outcomes in the included studies was low to moderate. Further systematic reviews and meta-analyses are needed to address the evidence gap regarding the supportive care for SARS, MERS and COVID-19.
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Affiliation(s)
- Xufei Luo
- School of Public Health, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China.,Evidence-based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
| | - Meng Lv
- School of Public Health, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China.,Evidence-based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
| | - Xiaoqing Wang
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Xin Long
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Mengjuan Ren
- School of Public Health, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
| | - Xianzhuo Zhang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, China
| | - Yunlan Liu
- School of Public Health, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
| | - Weiguo Li
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Qi Zhou
- The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, China
| | - Yanfang Ma
- Evidence-based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
| | - Toshio Fukuoka
- Emergency and Critical Care Center, the Department of General Medicine, Department of Research and Medical Education at Kurashiki Central Hospital, Kurashiki, Japan.,Advisory Committee in Cochrane Japan, Tokyo, Japan
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea.,Korea Cochrane Centre, Seoul, Korea
| | - Myeong Soo Lee
- Korea Institute of Oriental Medicine, Daejeon, Korea.,University of Science and Technology, Daejeon, Korea
| | - Zhengxiu Luo
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Enmei Liu
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing 400014, China.,Chongqing Key Laboratory of Pediatrics, Chongqing 400014, China
| | - Xiaohui Wang
- School of Public Health, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
| | - Yaolong Chen
- School of Public Health, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China.,Evidence-based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China.,Lanzhou University, an Affiliate of the Cochrane China Network, Lanzhou 730000, China.,Chinese GRADE Center, Lanzhou 730000, China.,Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou 730000, China
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Predictive survival factors of the traumatically injured on venovenous extracorporeal membrane oxygenation: A Bayesian model. J Trauma Acute Care Surg 2019; 88:153-159. [DOI: 10.1097/ta.0000000000002457] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Guilló Moreno V, Gutiérrez Martínez A, Romero Berrocal A, Sánchez Castilla M, García-Fernández J. Experience in the management of ECMO therapy as a mortality risk factor. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2018; 65:90-95. [PMID: 29110890 DOI: 10.1016/j.redar.2017.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 08/13/2017] [Accepted: 09/20/2017] [Indexed: 06/07/2023]
Abstract
INTRODUCTION The extracorporeal oxygenation membrane (ECMO) is a system that provides circulatory and respiratory assistance to patients in cardiac or respiratory failure refractory to conventional treatment. It is a therapy with numerous associated complications and high mortality. Multidisciplinary management and experienced teams increase survival. OBJECTIVE Our purpose is to evaluate and analyse the effect of the learning curve on mortality. METHODS Retrospective and observational study of 31 patients, from January 2012 to December 2015. Patients were separated into 2periods. These periods were divided by the establishment of an ECMO protocol. We compared the quantitative variables by performing the Mann-Whitney U test. For the categorical qualitative variables we performed the chi-square test or Fisher exact statistic as appropriate. The survival curve was computed using the Kaplan-Meier method, and the analysis of statistical significance using the Log-rank test. Data analysis was performed with the STATA programme 14. RESULTS Survival curves show the tendency to lower mortality in the subsequent period (P=0.0601). The overall mortality rate in the initial period was higher than in the subsequent period (P=0.042). In another analysis, we compared the characteristics of the 2groups and concluded that they were homogeneous. CONCLUSION The degree of experience is an independent factor for mortality. The application of a care protocol is fundamental to facilitate the management of ECMO therapy.
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Affiliation(s)
- V Guilló Moreno
- Servicio de Anestesia y Reanimación, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España.
| | - A Gutiérrez Martínez
- Servicio de Anestesia y Reanimación, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - A Romero Berrocal
- Servicio de Anestesia y Reanimación, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - M Sánchez Castilla
- Servicio de Anestesia y Reanimación, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - J García-Fernández
- Servicio de Anestesia y Reanimación, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
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Della Torre V, Badenes R, Corradi F, Racca F, Lavinio A, Matta B, Bilotta F, Robba C. Acute respiratory distress syndrome in traumatic brain injury: how do we manage it? J Thorac Dis 2017; 9:5368-5381. [PMID: 29312748 PMCID: PMC5756968 DOI: 10.21037/jtd.2017.11.03] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 10/31/2017] [Indexed: 12/24/2022]
Abstract
Traumatic brain injury (TBI) is an important cause of morbidity and mortality worldwide. TBI patients frequently suffer from lung complications and acute respiratory distress syndrome (ARDS), which is associated with poor clinical outcomes. Moreover, the association between TBI and ARDS in trauma patients is well recognized. Mechanical ventilation of patients with a concomitance of acute brain injury and lung injury can present significant challenges. Frequently, guidelines recommending management strategies for patients with traumatic brain injuries come into conflict with what is now considered best ventilator practice. In this review, we will explore the strategies of the best practice in the ventilatory management of patients with ARDS and TBI, concentrating on those areas in which a conflict exists. We will discuss the use of ventilator strategies such as protective ventilation, high positive end expiratory pressure (PEEP), prone position, recruitment maneuvers (RMs), as well as techniques which at present are used for 'rescue' in ARDS (including extracorporeal membrane oxygenation) in patients with TBI. Furthermore, general principles of fluid, haemodynamic and hemoglobin management will be discussed. Currently, there are inadequate data addressing the safety or efficacy of ventilator strategies used in ARDS in adult patients with TBI. At present, choice of ventilator rescue strategies is best decided on a case-by-case basis in conjunction with local expertise.
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Affiliation(s)
- Valentina Della Torre
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Rafael Badenes
- Department of Anesthesiology and Surgical Trauma Intensive Care, Hospital Clinic Universitari Valencia, University of Valencia, Valencia, Spain
| | | | - Fabrizio Racca
- Department of Anesthesiology and Intensive Care Unit, SS Antonio Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Lavinio
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Federico Bilotta
- Department of Anaesthesia and Intensive Care, La Sapienza University, Rome, Italy
| | - Chiara Robba
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Department of Neuroscience, University of Genova, Italy
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Lopez Saubidet I, Maskin LP, Rodríguez PO, Bonelli I, Setten M, Valentini R. Mortality in patients with respiratory distress syndrome. Med Intensiva 2015; 40:356-63. [PMID: 26746127 DOI: 10.1016/j.medin.2015.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/15/2015] [Accepted: 10/23/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Mortality in Acute Respiratory Distress Syndrome (ARDS) is decreasing, although its prognosis after hospital discharge and the prognostic accuracy of Berlin's new ARDS stratification are uncertain. METHODS We did a restrospective analysis of hospital and 6 month mortality of patients with ARDS admitted to the Intensive Care Unit of a Univeristy Hospital in Buenos Aires, between January 2008 and June 2011. ARDS was defined by PaO2/FiO2 lower than 200 mmHg under ventilation with at least 10 cm H2O of PEEP and a FiO2 higher or equal than 0.5. and the presence of bilateral infiltrates in chest radiography, in the absence of cardiogenic acute pulmonary edema, during the first 72 hs of mechanical ventilation. Mortality associated risk factors, the use of rescue therapies and Berlin's stratification for moderate and severe ARDS patients were considered. RESULTS Ninety eight patients were included; mean age was 59±19 years old, 42,9% had mayor co-morbidities; APACHE II at admission was 22±7; SOFA at day 1 was 8±3. Prone position ventilation was applied in 20,4% and rescue measures in 12,2% (12 patients with nitric oxide and 1 with extracorporeal membrane oxygenation). Hospital and 6 months mortality were 37.7 and 43.8% respectively. After logistic regression analysis, only age, the presence of septic shock at admission, Ppl >30 cmH2O, and major co-morbidities were independently associated with hospital outcome. There was no difference between moderate and severe groups (41,2 and 36,8% respectively; p=0,25). CONCLUSION In this cohort, including patients with severe hypoxemia and high percentage of mayor co-morbidities, ARDS associated mortality was lower than some previous studies. There was no increase in mortality after hospital discharge. There was no difference in mortality between moderate and severe groups according to Berlin's definition.
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Affiliation(s)
- I Lopez Saubidet
- Terapia Intensiva, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno, CEMIC , Buenos Aires, Argentina.
| | - L P Maskin
- Terapia Intensiva, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno, CEMIC , Buenos Aires, Argentina
| | - P O Rodríguez
- Terapia Intensiva, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno, CEMIC , Buenos Aires, Argentina
| | - I Bonelli
- Terapia Intensiva, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno, CEMIC , Buenos Aires, Argentina
| | - M Setten
- Terapia Intensiva, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno, CEMIC , Buenos Aires, Argentina
| | - R Valentini
- Terapia Intensiva, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno, CEMIC , Buenos Aires, Argentina
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Tramm R, Ilic D, Davies AR, Pellegrino VA, Romero L, Hodgson C. Extracorporeal membrane oxygenation for critically ill adults. Cochrane Database Syst Rev 2015; 1:CD010381. [PMID: 25608845 PMCID: PMC6353247 DOI: 10.1002/14651858.cd010381.pub2] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a form of life support that targets the heart and lungs. Extracorporeal membrane oxygenation for severe respiratory failure accesses and returns blood from the venous system and provides non-pulmonary gas exchange. Extracorporeal membrane oxygenation for severe cardiac failure or for refractory cardiac arrest (extracorporeal cardiopulmonary resuscitation (ECPR)) provides gas exchange and systemic circulation. The configuration of ECMO is variable, and several pump-driven and pump-free systems are in use. Use of ECMO is associated with several risks. Patient-related adverse events include haemorrhage or extremity ischaemia; circuit-related adverse effects may include pump failure, oxygenator failure and thrombus formation. Use of ECMO in newborns and infants is well established, yet its clinical effectiveness in adults remains uncertain. OBJECTIVES The primary objective of this systematic review was to determine whether use of veno-venous (VV) or venous-arterial (VA) ECMO in adults is more effective in improving survival compared with conventional respiratory and cardiac support. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and EMBASE (Ovid) on 18 August 2014. We searched conference proceedings, meeting abstracts, reference lists of retrieved articles and databases of ongoing trials and contacted experts in the field. We imposed no restrictions on language or location of publications. SELECTION CRITERIA We included randomized controlled trials (RCTs), quasi-RCTs and cluster-RCTs that compared adult ECMO versus conventional support. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of all retrieved citations against the inclusion criteria. We independently reviewed full-text copies of studies that met the inclusion criteria. We entered all data extracted from the included studies into Review Manager. Two review authors independently performed risk of bias assessment. All included studies were appraised with respect to random sequence generation, concealment of allocation, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias. MAIN RESULTS We included four RCTs that randomly assigned 389 participants with acute respiratory failure. Risk of bias was low in three RCTs and high in one RCT. We found no statistically significant differences in all-cause mortality at six months (two RCTs) or before six months (during 30 days of randomization in one trial and during hospital stay in another RCT). The quality of the evidence was low to moderate, and further research is very likely to impact our confidence in the estimate of effects because significant changes have been noted in ECMO applications and treatment modalities over study periods to the present.Two RCTs supplied data on disability. In one RCT survival was low in both groups but none of the survivors had limitations in their daily activities six months after discharge. The other RCT reported improved survival without severe disability in the intervention group (transfer to an ECMO centre ± ECMO) six months after study randomization but no statistically significant differences in health-related quality of life.In three RCTs, participants in the ECMO group received greater numbers of blood transfusions. One RCT recorded significantly more non-brain haemorrhage in the ECMO group. Another RCT reported two serious adverse events in the ECMO group, and another reported three adverse events in the ECMO group.Clinical heterogeneity between studies prevented meta-analyses across outcomes. We found no completed RCT that had investigated ECMO in the context of cardiac failure or arrest. We found one ongoing RCT that examined patients with acute respiratory failure and two ongoing RCTs that included patients with acute cardiac failure (arrest). AUTHORS' CONCLUSIONS Extracorporeal membrane oxygenation remains a rescue therapy. Since the year 2000, patient treatment and practice with ECMO have considerably changed as the result of research findings and technological advancements over time. Over the past four decades, only four RCTs have been published that compared the intervention versus conventional treatment at the time of the study. Clinical heterogeneity across these published studies prevented pooling of data for a meta-analysis.We recommend combining results of ongoing RCTs with results of trials conducted after the year 2000 if no significant shifts in technology or treatment occur. Until these new results become available, data on use of ECMO in patients with acute respiratory failure remain inconclusive. For patients with acute cardiac failure or arrest, outcomes of ongoing RCTs will assist clinicians in determining what role ECMO and ECPR can play in patient care.
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Affiliation(s)
- Ralph Tramm
- Monash UniversityAustralian and New Zealand Intensive Care Research Centre (ANZIC‐RC), Department of Epidemiology and Preventive MedicineLevel 6 The Alfred Centre, 99 Commercial RoadMelbourneVictoriaAustralia3004
| | - Dragan Ilic
- Monash UniversityDepartment of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine553 St Kilda RoadMelbourneVictoriaAustralia3004
| | - Andrew R Davies
- Monash UniversityAustralian and New Zealand Intensive Care Research Centre (ANZIC‐RC), Department of Epidemiology and Preventive MedicineLevel 6 The Alfred Centre, 99 Commercial RoadMelbourneVictoriaAustralia3004
| | - Vincent A Pellegrino
- The Alfred HospitalDepartment of Intensive CareCommercial RoadMelbourneAustralia3181
| | - Lorena Romero
- The Alfred HospitalThe Ian Potter Library55 Commercial RoadMelbourneVictoriaAustralia3000
| | - Carol Hodgson
- Monash UniversityAustralian and New Zealand Intensive Care Research Centre (ANZIC‐RC), Department of Epidemiology and Preventive MedicineLevel 6 The Alfred Centre, 99 Commercial RoadMelbourneVictoriaAustralia3004
- The Alfred HospitalDepartment of PhysiotherapyMelbourneAustralia
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He C, Yang S, Yu W, Chen Q, Shen J, Hu Y, Shi J, Wu X, Li J, Li N. Effects of continuous renal replacement therapy on intestinal mucosal barrier function during extracorporeal membrane oxygenation in a porcine model. J Cardiothorac Surg 2014; 9:72. [PMID: 24758270 PMCID: PMC4013437 DOI: 10.1186/1749-8090-9-72] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 04/07/2014] [Indexed: 12/20/2022] Open
Abstract
Backgrounds Extracorporeal membrane oxygenation (ECMO) has been recommended for treatment of acute, potentially reversible, life-threatening respiratory failure unresponsive to conventional therapy. Intestinal mucosal barrier dysfunction is one of the most critical pathophysiological disorders during ECMO. This study aimed to determine whether combination with CRRT could alleviate damage of intestinal mucosal barrier function during VV ECMO in a porcine model. Methods Twenty-four piglets were randomly divided into control(C), sham(S), ECMO(E) and ECMO + CRRT(EC) group. The animals were treated with ECMO or ECMO + CRRT for 24 hours. After the experiments, piglets were sacrificed. Jejunum, ileum and colon were harvested for morphologic examination of mucosal injury and ultrastructural distortion. Histological scoring was assessed according to Chiu’s scoring standard. Blood samples were taken from the animals at -1, 2, 6, 12 and 24 h during experiment. Blood, liver, spleen, kidney and mesenteric lymphnode were collected for bacterial culture. Serum concentrations of diamine oxidase (DAO) and intestinal fatty acid binding protein (I-FABP) were tested as markers to assess intestinal epithelial function and permeability. DAO levels were determined by spectrophotometry and I-FABP levels by enzyme linked immunosorbent assay. Results Microscopy findings showed that ECMO-induced intestinal microvillus shedding and edema, morphological distortion of tight junction between intestinal mucous epithelium and loose cell-cell junctions were significantly improved with combination of CRRT. No significance was detected on positive rate of serum bacterial culture. The elevated colonies of bacterial culture in liver and mesenteric lymphnode in E group reduced significantly in EC group (p < 0.05). Compared with E group, EC group showed significantly decreased level of serum DAO and I-FABP (p < 0.05). Conclusions CRRT can alleviate the intestinal mucosal dysfunction and bacterial translocation during VV ECMO, which may extenuate the ECMO-associated SIRS and raise the clinical effect and safety.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ning Li
- Department of General Surgery, Jinling hospital, Medical School of Nanjing University, Nanjing 210002, P,R, China.
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Sajjad M, Osman A, Mohsen S, Alanazi M, Ugurlucan M, Canver C. Extracorporeal membrane oxygenation in adults: experience from the Middle East. Asian Cardiovasc Thorac Ann 2013; 21:521-7. [PMID: 24570552 DOI: 10.1177/0218492312460858] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The literature reports conflicting results for survival after extracorporeal membrane oxygenator support, and survival differs in pediatric and adult patients. We present our institutional experience of adult extracorporeal membrane oxygenator support. METHODS From January 2007 to December 2009, 19 adult patients required extracorporeal membrane oxygenator support after cardiac surgery or catheter interventions. It was provided on an emergency basis to 11 patients, urgently to 5, and electively to 3. Indications included post-cardiotomy cardiogenic shock, post-cardiotomy acute respiratory failure, emergency cardiac resuscitation, and post-percutaneous coronary intervention cardiogenic shock. The mean duration of support was 4 days (range, 1-11 days). RESULTS Seven (36.84%) patients could be weaned off extracorporeal membrane oxygenator support; one (14.28%) of them survived to hospital discharge and the other 6 (85.71%) died in hospital. Twelve (63.15%) patients could not be weaned off and died while still on extracorporeal membrane oxygenator support. Overall 30-day hospital mortality was 94.73%, and survival to discharge was 5.26%. CONCLUSION Our institutional experience of extracorporeal membrane oxygenator support for cardiac indications in adult patients indicates poor survival. It significantly increased costs by delaying imminent death and prolonging stay in the intensive care unit.
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Affiliation(s)
- Mohammad Sajjad
- Department of Adult Cardiac Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Yimin H, Wenkui Y, Jialiang S, Qiyi C, Juanhong S, Zhiliang L, Changsheng H, Ning L, Jieshou L. Effects of continuous renal replacement therapy on renal inflammatory cytokines during extracorporeal membrane oxygenation in a porcine model. J Cardiothorac Surg 2013; 8:113. [PMID: 23628149 PMCID: PMC3648370 DOI: 10.1186/1749-8090-8-113] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 03/26/2013] [Indexed: 11/13/2022] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) has been recommended for the treatment of patients with acute, potentially reversible, life-threatening respiratory failure which unresponsive to conventional therapy. But it is unclear about how ECMO affects renal tissue. Methods Twenty-four piglets weighing 25 to 32 kg were used in this experiment. The piglets were randomly allocated to 4 groups of 6 animals each: sham group (S group), control group (C group), VV-ECMO group (E group), VV-ECMO combined with CRRT group (EC group). The piglets were sacrificed and the kidney tissue were harvest to determine the levels of IL-1β, IL-6, TNF-α and NF-КB by using the ELISA and RT-PCR method, respectively. Results Compared with C group and S group, E group renal tissue IL-1β, IL-6, TNF-α and NF-КB expression increased significantly, respectively (p < 0.01). Compared with E group, EC group showed renal tissue IL-1β, IL-6, TNF-α and NF-КB expression decreased significantly, respectively (p < 0.05). Conclusion ECMO enables to inflammatory cytokines including IL-1β, IL-6, TNFα, NF-КB released significantly, renal function impaired and immune homeostasis were to imbalance; ECMO combined with CRRT treatment can alleviate levels of inflammatory cytokines, maintain immune homeostasis balance and thus ameliorate the ECMO-related acute kidney injury(AKI).
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Haushofer M, Abusabha Y, Amerini ALA, Spillner J, Nix C, Autschbach R, Goetzenich A, Hatam N. Oxygenated shunting from right to left: a feasibility study of minimized atrio-atrial extracorporeal membrane oxygenation for mid-term lung assistance in an acute ovine model. Interact Cardiovasc Thorac Surg 2013; 17:44-8. [PMID: 23543405 DOI: 10.1093/icvts/ivt074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Right ventricular failure is often the final phase in acute and chronic respiratory failure. We combined right ventricular unloading with extracorporeal oxygenation in a new atrio-atrial extracorporeal membrane oxygenation (ECMO). METHODS Eleven sheep (65 kg) were cannulated by a 28-Fr inflow cannula to the right atrium and a 25-Fr outflow cannula through the lateral left atrial wall. Both were connected by a serial combination of a microaxial pump (Impella Elect(®), Abiomed Europe, Aachen, Germany) and a membrane oxygenator (Novalung(®)-iLA membrane oxygenator; Novalung GmbH, Hechingen, Germany). In four animals, three subsequent states were evaluated: normal circulation, apneic hypoxia and increased right atrial after load by pulmonary banding. We focused on haemodynamic stability and gas exchange. RESULTS All animals reached the end of the study protocol. In the apnoea phase, the decrease in PaO2 (21.4 ± 3.6 mmHg) immediately recovered (179.1 ± 134.8 mmHg) on-device in continuous apnoea. Right heart failure by excessive after load decreased mean arterial pressure (59 ± 29 mmHg) and increased central venous pressure and systolic right ventricular pressure; PaO2 and SvO2 decreased significantly. On assist, mean arterial pressure (103 ± 29 mmHg), central venous pressure and right ventricular pressure normalized. The SvO2 increased to 89 ± 3% and PaO2 stabilized (129 ± 21 mmHg). CONCLUSIONS We demonstrated the efficacy of a miniaturized atrio-atrial ECMO. Right ventricular unloading was achieved, and gas exchange was well taken over by the Novalung. This allows an effective short- to mid-term treatment of cardiopulmonary failure, successfully combining right ventricular and respiratory bridging. The parallel bypass of the right ventricle and lung circulation permits full unloading of both systems as well as gradual weaning. Further pathologies (e.g. ischaemic right heart failure and acute lung injury) will have to be evaluated.
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Affiliation(s)
- Marcus Haushofer
- Department of Cardiothoracic and Vascular Surgery, RWTH Aachen University Hospital, Aachen, Germany.
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Lin MW, Huang SC, Kuo SW, Huang PM, Hsu HH, Lee YC. Lobar torsion after lung transplantation. J Formos Med Assoc 2013; 112:105-8. [DOI: 10.1016/j.jfma.2012.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Revised: 08/24/2009] [Accepted: 09/30/2009] [Indexed: 10/27/2022] Open
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Schmidt M, Tachon G, Devilliers C, Muller G, Hekimian G, Bréchot N, Merceron S, Luyt CE, Trouillet JL, Chastre J, Leprince P, Combes A. Blood oxygenation and decarboxylation determinants during venovenous ECMO for respiratory failure in adults. Intensive Care Med 2013; 39:838-46. [DOI: 10.1007/s00134-012-2785-8] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 12/05/2012] [Indexed: 12/21/2022]
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Sanchez-Lorente D, Iglesias M, Rodríguez A, Jungebluth P, Macchiarini P. The pumpless extracorporeal lung membrane provides complete respiratory support during complex airway reconstructions without inducing cellular trauma or a coagulatory and inflammatory response. J Thorac Cardiovasc Surg 2012; 144:425-30. [DOI: 10.1016/j.jtcvs.2012.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 03/09/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022]
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Huang PM, Ko WJ, Tsai PR, Kuo SW, Hsu HH, Chen JS, Lee JM, Lee YC. Aggressive management of massive hemothorax in patients on extracorporeal membrane oxygenation. Asian J Surg 2012; 35:16-22. [DOI: 10.1016/j.asjsur.2012.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 04/11/2011] [Accepted: 09/04/2011] [Indexed: 11/28/2022] Open
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Park PK, Napolitano LM, Bartlett RH. Extracorporeal Membrane Oxygenation in Adult Acute Respiratory Distress Syndrome. Crit Care Clin 2011; 27:627-46. [DOI: 10.1016/j.ccc.2011.05.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Extracorporeal membrane oxygenation (ECMO) pour les syndromes de détresse respiratoire aiguë (SDRA) sévères. L’essai EOLIA (ECMO to rescue Lung Injury in severe ARDS): un essai multicentrique international, randomisé, contrôlé en ouvert. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s13546-010-0002-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Guan Y, Karkhanis T, Wang S, Rider A, Koenig SC, Slaughter MS, El Banayosy A, Ündar A. Physiologic Benefits of Pulsatile Perfusion During Mechanical Circulatory Support for the Treatment of Acute and Chronic Heart Failure in Adults. Artif Organs 2010; 34:529-36. [DOI: 10.1111/j.1525-1594.2010.00996.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wiebe K, Poeling J, Arlt M, Philipp A, Camboni D, Hofmann S, Schmid C. Thoracic Surgical Procedures Supported by a Pumpless Interventional Lung Assist. Ann Thorac Surg 2010; 89:1782-7; discussion 1788. [DOI: 10.1016/j.athoracsur.2010.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 03/01/2010] [Accepted: 03/01/2010] [Indexed: 10/19/2022]
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Mitchell MD, Mikkelsen ME, Umscheid CA, Lee I, Fuchs BD, Halpern SD. A systematic review to inform institutional decisions about the use of extracorporeal membrane oxygenation during the H1N1 influenza pandemic. Crit Care Med 2010; 38:1398-404. [PMID: 20400902 PMCID: PMC4162635 DOI: 10.1097/ccm.0b013e3181de45db] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To systematically evaluate the effect of extracorporeal membrane oxygenation on survival in adults with acute respiratory failure and to help inform institutional decisions about implementing an extracorporeal membrane oxygenation program or transferring patients to experienced extracorporeal membrane oxygenation centers during the H1N1 influenza pandemic. DATA SOURCES National Guideline Clearinghouse, MEDLINE, EMBASE, Agency for Healthcare Research and Quality Evidence-based Practice reports, National Institute for Health and Clinical Excellence, Cochrane Library, International Network of Agencies for Health Technology Assessment, and citation review. STUDY SELECTION Studies of extracorporeal membrane oxygenation in adult acute respiratory failure, reporting mortality rates for at least 10 patients in extracorporeal membrane oxygenation and nonextracorporeal membrane oxygenation groups. DATA EXTRACTION Mortality rates were abstracted for all patients and for patients with influenza. Risk ratios were meta-analyzed using random-effects methods and assessed for heterogeneity. DATA SYNTHESIS There are no evidence-based clinical guidelines on the use of extracorporeal membrane oxygenation in patients with influenza. Three randomized controlled trials and three cohort studies evaluated extracorporeal membrane oxygenation in patients with acute respiratory failure; none reported specifically on patients with influenza. Meta-analysis of the randomized controlled trials revealed significant heterogeneity in risk of mortality. The summary risk ratio found by the meta-analysis was 0.93 (95% confidence interval, 0.71 to 1.22). The most recent trial found a reduction in mortality and severe disability at 6 months among patients in whom extracorporeal membrane oxygenation was considered. Observational studies suggest that extracorporeal membrane oxygenation for acute respiratory failure resulting from viral pneumonia is associated with improved mortality compared with other etiologies of acute respiratory failure. CONCLUSIONS The best evidence to guide decisions regarding the use of extracorporeal membrane oxygenation for patients with influenza stems from trials of extracorporeal membrane oxygenation for acute respiratory failure of all etiologies, among which significant heterogeneity exists, and from case series describing outcomes of extracorporeal membrane oxygenation in patients with influenza. Thus, there is insufficient evidence to provide a recommendation for extracorporeal membrane oxygenation use among patients with respiratory failure resulting from influenza. However, clinicians should consider extracorporeal membrane oxygenation within the context of other salvage therapies for acute respiratory failure.
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Affiliation(s)
- Matthew D. Mitchell
- Center for Evidence-based Practice, University of Pennsylvania Health System
| | - Mark E. Mikkelsen
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania
| | - Craig A. Umscheid
- Center for Evidence-based Practice, University of Pennsylvania Health System
- Division of General Internal Medicine, Department of Medicine, Hospital of the University of Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine
| | - Ingi Lee
- Center for Evidence-based Practice, University of Pennsylvania Health System
- Division of Infectious Diseases, Department of Medicine, Hospital of the University of Pennsylvania
| | - Barry D. Fuchs
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania
| | - Scott D. Halpern
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine
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Gow KW, Lao OB, Leong T, Fortenberry JD. Extracorporeal life support for adults with malignancy and respiratory or cardiac failure: The Extracorporeal Life Support experience. Am J Surg 2010; 199:669-75. [DOI: 10.1016/j.amjsurg.2010.01.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 01/13/2010] [Accepted: 01/13/2010] [Indexed: 12/12/2022]
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Opdahl H. [Acute respiratory failure concomitant with serious disease or injury]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:154-7. [PMID: 20125207 DOI: 10.4045/tidsskr.08.0072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Acute respiratory failure has an annual incidence of 20-75/100,000 and is the most common reason for admittance to an intensive care unit. A common cause is acute inflammatory changes in lung tissue. The article reviews clinical, etiological, pathophysiological and therapeutic aspects of acute respiratory failure, with an emphasis on failure secondary to proinflammatory processes. MATERIAL AND METHODS This paper is not based on a comprehensive literature review, but on the clinical and scientific experience of the author, literature from a private archive and a limited Medline search. RESULTS Acute respiratory failure can be precipitated by agents and/or trauma that damage the lungs directly. Serious infections and tissue damage located in other parts of the body can also cause respiratory failure. In these cases, the blood transports activated blood cells and proinflammatory agents to the lungs where they induce secondary tissue inflammation. The resulting respiratory failure is often serious. Mortality is in the range 30-50 %. INTERPRETATION No specific treatment is available for secondary tissue inflammation; it usually resolves when the precipitating injuries or disease processes are healed. Positive pressure ventilation can prevent serious hypoxemia from causing additional damage to affected tissue. With modern treatment in an intensive care unit only 10-15 % of the deaths are caused by the respiratory failure per se, most deaths are caused by failure of several additional organs (multiorgan failure).
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Affiliation(s)
- Helge Opdahl
- Nasjonalt kompetansesenter for NBC-medisin, Oslo universitetssykehus, Ullevål, 0407 Oslo, Norway.
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