title: A systematic review to inform institutional decisions about the use of extracorporeal membrane oxygenation during the H1N1 influenza pandemic.
abstract: 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.
authors.affiliation: Center for Evidence-Based Practice, University of Pennsylvania Health System, Philadelphia, PA, USA.
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Mitchell
authors.forename: Mark E
authors.initials: ME
authors.lastname: Mikkelsen
authors.forename: Craig A
authors.initials: CA
authors.lastname: Umscheid
authors.forename: Ingi
authors.initials: I
authors.lastname: Lee
authors.forename: Barry D
authors.initials: BD
authors.lastname: Fuchs
authors.forename: Scott D
authors.initials: SD
authors.lastname: Halpern
mesh_terms: 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
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