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Extracorporeal membrane oxygenation in severe influenza infection with respiratory failure: A systematic review and meta-analysis


1 Division of Pulmonary, Critical Care and Sleep Medicine, John H Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
2 Department of Internal Medicine, John H Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
3 Division of Cardiovascular Diseases, Montefiore Medical Center, Albert Einstein College of Medicine, New York, USA
4 Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
5 Department of Anesthesiology, Mayo Clinic College of Medicine, Scottsdale; Department of Anesthesiology, Mayo Clinic, Phoenix, AZ 85054, USA

Correspondence Address:
Shashvat Sukhal
Division of Pulmonary, Critical Care Medicine, and Sleep Medicine, John H Stroger, Jr. Hospital of Cook County, Room 1423, 1900 West Polk Street, Chicago 60612, Illinois
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.197820

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Year : 2017  |  Volume : 20  |  Issue : 1  |  Page : 14-21

 

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Introduction: Extracorporeal membrane oxygenation (ECMO) has been extensively used for potentially reversible acute respiratory failure associated with severe influenza A (H1N1) pneumonia; however, it remains an expensive, resource-intensive therapy, with a high associated mortality. This systematic review and meta-analysis aims to summarize and pool outcomes data available in the published literature to guide clinical decision-making and further research. Methods: We conducted a systematic search of MEDLINE (1966 to April 15, 2015), EMBASE (1980 to April 15, 2015), CENTRAL, and Google Scholar for patients with severe H1N1 pneumonia and respiratory failure who received ECMO. The study validity was appraised by Newcastle-Ottawa Scale. The primary outcome was all-cause mortality. The secondary outcomes were duration of ECMO therapy, mechanical ventilation, and Intensive Care Unit (ICU) length of stay. Results: Of 698 abstracts screened and 142 full-text articles reviewed, we included 13 studies with a total of 494 patients receiving ECMO in our final review and meta-analysis. The study validity was satisfactory. The overall mortality was 37.1% (95% confidence interval: 30-45%) limited by underlying heterogeneity (I2 = 65%, P value of Q statistic = 0.006). The median duration for ECMO was 10 days, mechanical ventilation was 19 days, and ICU length of stay was 33 days. Exploratory meta-regression did not identify any statistically significant moderator of mortality (P < 0.05), except for the duration of pre-ECMO mechanical ventilation in days (coefficient 0.19, standard error: 0.09, Z = 2.01, P < 0.04, R2 = 0.16). The visual inspection of funnel plots did not suggest the presence of publication bias. Conclusions: ECMO therapy may be used as an adjunct or salvage therapy for severe H1N1 pneumonia with respiratory failure. It is associated with a prolonged duration of ventilator support, ICU length of stay, and high mortality. Initiating ECMO early once the patient has been instituted on mechanical ventilation may result in improved survival.






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1 Division of Pulmonary, Critical Care and Sleep Medicine, John H Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
2 Department of Internal Medicine, John H Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
3 Division of Cardiovascular Diseases, Montefiore Medical Center, Albert Einstein College of Medicine, New York, USA
4 Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
5 Department of Anesthesiology, Mayo Clinic College of Medicine, Scottsdale; Department of Anesthesiology, Mayo Clinic, Phoenix, AZ 85054, USA

Correspondence Address:
Shashvat Sukhal
Division of Pulmonary, Critical Care Medicine, and Sleep Medicine, John H Stroger, Jr. Hospital of Cook County, Room 1423, 1900 West Polk Street, Chicago 60612, Illinois
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.197820

Rights and Permissions

Introduction: Extracorporeal membrane oxygenation (ECMO) has been extensively used for potentially reversible acute respiratory failure associated with severe influenza A (H1N1) pneumonia; however, it remains an expensive, resource-intensive therapy, with a high associated mortality. This systematic review and meta-analysis aims to summarize and pool outcomes data available in the published literature to guide clinical decision-making and further research. Methods: We conducted a systematic search of MEDLINE (1966 to April 15, 2015), EMBASE (1980 to April 15, 2015), CENTRAL, and Google Scholar for patients with severe H1N1 pneumonia and respiratory failure who received ECMO. The study validity was appraised by Newcastle-Ottawa Scale. The primary outcome was all-cause mortality. The secondary outcomes were duration of ECMO therapy, mechanical ventilation, and Intensive Care Unit (ICU) length of stay. Results: Of 698 abstracts screened and 142 full-text articles reviewed, we included 13 studies with a total of 494 patients receiving ECMO in our final review and meta-analysis. The study validity was satisfactory. The overall mortality was 37.1% (95% confidence interval: 30-45%) limited by underlying heterogeneity (I2 = 65%, P value of Q statistic = 0.006). The median duration for ECMO was 10 days, mechanical ventilation was 19 days, and ICU length of stay was 33 days. Exploratory meta-regression did not identify any statistically significant moderator of mortality (P < 0.05), except for the duration of pre-ECMO mechanical ventilation in days (coefficient 0.19, standard error: 0.09, Z = 2.01, P < 0.04, R2 = 0.16). The visual inspection of funnel plots did not suggest the presence of publication bias. Conclusions: ECMO therapy may be used as an adjunct or salvage therapy for severe H1N1 pneumonia with respiratory failure. It is associated with a prolonged duration of ventilator support, ICU length of stay, and high mortality. Initiating ECMO early once the patient has been instituted on mechanical ventilation may result in improved survival.






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