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- Title
Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.
- Authors
Hajage, David; Combes, Alain; Guervilly, Christophe; Lebreton, Guillaume; Mercat, Alain; Pavot, Arthur; Nseir, Saad; Mekontso-Dessap, Armand; Mongardon, Nicolas; Mira, Jean Paul; Ricard, Jean-Damien; Beurton, Alexandra; Tachon, Guillaume; Kontar, Loay; Le Terrier, Christophe; Richard, Jean Christophe; Mégarbane, Bruno; Keogh, Ruth H.; Belot, Aurélien; Maringe, Camille
- Abstract
<bold>Rationale: </bold>Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown.<bold>Objectives: </bold>To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 <80 or PaCO2 ≥60 mmHg). We controlled for confounding using a multivariable Cox model based on predefined variables.<bold>Main Results: </bold>1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability at Day-7 from the onset of eligibility criteria (87% vs 83%, risk difference: 4%, 95% CI 0;9%) which decreased during follow-up (survival at Day-90: 63% vs 65%, risk difference: -2%, 95% CI -10;5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand, and when initiated within the first 4 days of MV and in profoundly hypoxemic patients.<bold>Conclusions: </bold>In an emulated trial based on a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and in regions with ECMO capacities specifically organized to handle high demand. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
- Publication
American Journal of Respiratory & Critical Care Medicine, 2022, Vol 206, Issue 3, p281
- ISSN
1073-449X
- Publication type
Article
- DOI
10.1164/rccm.202111-2495OC