A systematic review to inform institutional decisions about the use of extracorporeal membrane oxygenation during the H1N1 influenza pandemic.
OBJECTIVE
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.


METHODS
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.


METHODS
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.


METHODS
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.


RESULTS
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.
Mitchell
Matthew D
MD
Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia, PA, USA.
Mikkelsen
Mark E
ME
Umscheid
Craig A
CA
Lee
Ingi
I
Fuchs
Barry D
BD
Halpern
Scott D
SD
D000328:Adult; D004196:Disease Outbreaks; D015199:Extracorporeal Membrane Oxygenation; D006801:Humans; D053118:Influenza A Virus, H1N1 Subtype; D007251:Influenza, Human / Q000150:complications / Q000453:epidemiology* / Q000628:therapy*; D012131:Respiratory Insufficiency / Q000401:mortality / Q000628:therapy* / Q000821:virology*; D015996:Survival Rate; D014481:United States
JAMA. 2009 Nov 4;302(17):1888-95
19822628
N Engl J Med. 2000 May 4;342(18):1301-8
10793162
Control Clin Trials. 1996 Feb;17(1):1-12
8721797
Arch Surg. 2009 May;144(5):427-32; discussion 432
19451484
JAMA. 2009 Nov 4;302(17):1872-9
19822627
Chest. 2008 May;133(5):1120-7
18263687
Control Clin Trials. 1981 May;2(1):31-49
7261638
JAMA. 2009 Nov 4;302(17):1880-7
19822626
ASAIO J. 2005 Jan-Feb;51(1):4-10
15745126
Intensive Care Med. 2006 Oct;32(10):1627-31
16874497
Ann Surg. 1997 Oct;226(4):544-64; discussion 565-6
9351722
Intensive Care Med. 1997 Aug;23(8):819-35
9310799
Int J Artif Organs. 1995 Oct;18(10):607-10
8647592
Am J Respir Crit Care Med. 1994 Feb;149(2 Pt 1):295-305
8306022
JAMA. 1979 Nov 16;242(20):2193-6
490805
Chest. 1997 Sep;112(3):759-64
9315812
ASAIO J. 2009 Jan-Feb;55(1):47-52
19092662
Ann Surg. 2004 Oct;240(4):595-605; discussion 605-7
15383787
N Engl J Med. 2006 Jul 6;355(1):41-50
16822995
Crit Care Med. 2008 Mar;36(3):724-30
18209667
Am J Surg. 2000 Aug;180(2):144-54
11044532
Anaesth Intensive Care. 2008 Mar;36(2):152-61
18361004
Lancet. 2009 Oct 17;374(9698):1351-63
19762075
Intensive Care Med. 2010 Jan;36(1):33-41
19924393
BMJ. 2003 Sep 6;327(7414):557-60
12958120