Comparison of venovenous extracorporeal membrane oxygenation, prone position and supine mechanical ventilation for severely hypoxemic acute respiratory distress syndrome: a network meta-analysis,Intensive Care Medicine

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Comparison of venovenous extracorporeal membrane oxygenation, prone position and supine mechanical ventilation for severely hypoxemic acute respiratory distress syndrome: a network meta-analysis
Intensive Care Medicine ( IF 27.1 ) Pub Date : 2024-06-06 , DOI: 10.1007/s00134-024-07492-7
Sachin Sud _{1,

2} , Eddy Fan _{3,

4} , Neill K J Adhikari _{3,

4,

5} , Jan O Friedrich ₃ , Niall D Ferguson _{3,

4} , Alain Combes _{6,

7} , Claude Guerin ₈ , Gordon Guyatt ₉

Affiliation

Purpose

Severe acute respiratory distress syndrome (ARDS) with PaO₂/FiO₂ < 80 mmHg is a life-threatening condition. The optimal management strategy is unclear. The aim of this meta-analysis was to compare the effects of low tidal volumes (V_t), moderate V_t, prone ventilation, and venovenous extracorporeal membrane oxygenation (VV-ECMO) on mortality in severe ARDS.

Methods

We performed a frequentist network meta-analysis of randomised controlled trials (RCTs) with participants who had severe ARDS and met eligibility criteria for VV-ECMO or had PaO₂/FiO₂ < 80 mmHg. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to discern the relative effect of interventions on mortality and the certainty of the evidence.

Results

Ten RCTs including 812 participants with severe ARDS were eligible. VV-ECMO reduces mortality compared to low V_t (risk ratio [RR] 0.77, 95% confidence interval [CI] 0.59–0.99, moderate certainty) and compared to moderate V_t (RR 0.75, 95% CI 0.57–0.98, low certainty). Prone ventilation reduces mortality compared to moderate V_t (RR 0.78, 95% CI 0.66–0.93, high certainty) and compared to low V_t (RR 0.81, 95% CI 0.63–1.02, moderate certainty). We found no difference in the network comparison of VV-ECMO compared to prone ventilation (RR 0.95, 95% CI 0.72–1.26), but inferences were based solely on indirect comparisons with very low certainty due to very wide confidence intervals.

Conclusions

In adults with ARDS and severe hypoxia, both VV-ECMO (low to moderate certainty evidence) and prone ventilation (moderate to high certainty evidence) improve mortality relative to low and moderate V_t strategies. The impact of VV-ECMO versus prone ventilation remains uncertain.

中文翻译：

静脉体外膜氧合、俯卧位和仰卧位机械通气治疗严重低氧血症急性呼吸窘迫综合征的比较：网络荟萃分析

目的

PaO ₂ /FiO ₂ < 80 mmHg 的严重急性呼吸窘迫综合征 (ARDS) 是一种危及生命的疾病。最佳管理策略尚不明确。本荟萃分析的目的是比较低潮气量 ( V _t )、中等潮气量( V _t )、俯卧位通气和静脉体外膜氧合 (VV-ECMO) 对严重 ARDS 死亡率的影响。

方法

我们对患有严重 ARDS 且符合 VV-ECMO 资格标准或 PaO ₂ /FiO ₂ < 80 mmHg 的参与者进行了随机对照试验 (RCT) 的频率网络荟萃分析。我们应用推荐、评估、发展和评价等级 (GRADE) 方法来辨别干预措施对死亡率和证据确定性的相对影响。

结果

包括 812 名患有严重 ARDS 的参与者在内的 10 项随机对照试验符合资格。与低V _t相比（风险比 [RR] 0.77，95% 置信区间 [CI] 0.59–0.99，中等确定性）以及与中V _t相比（RR 0.75，95% CI 0.57–0.98，低确定性），VV-ECMO 可降低死亡率肯定）。与中等Vt （RR 0.78，95% CI 0.66-0.93，高确定性）和低Vt （ _RR 0.81，95% CI 0.63-1.02，中等确定性）相比_，俯卧位通气可降低死亡率。我们发现 VV-ECMO 与俯卧位通气的网络比较没有差异（RR 0.95，95% CI 0.72-1.26），但推论仅基于间接比较，由于置信区间非常宽，因此确定性非常低。