Abstract
IntroductionPatients with acute respiratory failure requiring respiratory support with invasive mechanical ventilation while awaiting lung transplantation are at a high risk of death. Extracorporeal membrane oxygenation (ECMO) has been proposed as an alternative bridging strategy to mechanical ventilation. The aim of this study was to assess the current evidence regarding how the ECMO bridge influences patients’ survival and length of hospital stay.MethodsWe performed a systematic review by searching PubMed, EMBASE and the bibliographies of retrieved articles. Three reviewers independently screened citation titles and abstracts and agreement was reached by consensus. We selected studies enrolling patients who received ECMO with the intention to bridge lung transplant. We included randomized controlled trials (RCTs), case–control studies and case series with ten or more patients. Outcomes of interest included survival and length of hospital stay. Quantitative data summaries were made when feasible.ResultsWe identified 82 studies, of which 14 were included in the final analysis. All 14 were retrospective studies which enrolled 441 patients in total. Because of the broad heterogeneity among the studies we did not perform a meta-analysis. The mortality rate of patients on ECMO before lung transplant and the one-year survival ranged from 10% to 50% and 50% to 90%, respectively. The intensive care and hospital length of stay ranged between a median of 15 to 47 days and 22 to 47 days, respectively. There was a general paucity of high-quality data and significant heterogeneity among studies in the enrolled patients and technology used, which confounded analysis.ConclusionsIn most of the studies, patients on ECMO while awaiting lung transplantation also received invasive mechanical ventilation. Therefore, whether ECMO as an alternative, rather than an adjunction, to invasive mechanical ventilation is a better bridging strategy to lung transplantation still remains an unresolved issue. ECMO support as a bridge for these patients could provide acceptable one-year survival. Future studies are needed to investigate ECMO as part of an algorithm of care for patients with end-stage lung disease.
Highlights
Patients with acute respiratory failure requiring respiratory support with invasive mechanical ventilation while awaiting lung transplantation are at a high risk of death
Contributing to this high mortality rate is the lack of efficacious and safe means of artificial respiratory support for patients awaiting the transplant once they develop acute respiratory failure with refractory hypoxemia and hypercapnia [4,7]
Study selection and characteristics The initial search strategy identified 82 potentially eligible studies (Figure 1); 69 studies were excluded for the following reasons: 5 involved pediatric patients, 27 were deemed not relevant and 37 were case series, reviews, letters or congress proceedings
Summary
Patients with acute respiratory failure requiring respiratory support with invasive mechanical ventilation while awaiting lung transplantation are at a high risk of death. The significantly larger number of candidates than available organs explains the long waiting times and high risk of perioperative morbidity and mortality [1,4,5,6]. Contributing to this high mortality rate is the lack of efficacious and safe means of artificial respiratory support for patients awaiting the transplant once they develop acute respiratory failure with refractory hypoxemia and hypercapnia [4,7]. Ventilated pre-transplant patients have been reported to have significantly higher post-transplant mortality rates than non-ventilated patients [11,12]
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