October 9, 2011 by staff
H1N1 Treatment, Patients with severe respiratory failure due to the H1N1 influenza pandemic were less likely to die if they were treated with extracorporeal membrane oxygenation (ECMO) in place of standard mechanical ventilation, the researchers reported.
The risk of death among patients treated with ECMO was approximately half of patients who received standard therapy during the winter of 2009/2010, according to Giles Peek, MD, of Glenfield Hospital in Leicester, England, and colleagues.
The finding comes from ananlysis of patients in pigs in the UK, flu Triage Study (known as SWIFT), a prospective cohort of patients with suspected or confirmed H1N1 in need of critical care Peek, and colleagues reported online in the Journal of the American Medical Association.
The study was released early to coincide with a presentation at the meeting of the European Society of Intensive Care Medicine in Berlin.
The use of extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome (ARDS) has been controversial for two reasons: It has not been convincingly demonstrated that the benefits observed are due only to the ECMO and the procedure is more expensive than standard treatment.
During the winter the pandemic, 80 patients were referred to the four ECMO centers in the United Kingdom, of whom 69 received ECMO, the researchers reported. Of those patients, 22 (27.5%) died before discharge.
To see how it compares with standard therapy, the researchers compared patients with ECMO cohort members SWIFT received usual care in other facilities, using three different statistical methods: individual game, propensity score, and matching GenMatch.
Regardless of the method, it was reported that the mortality rate among patients without ECMO was almost double that of the ECMO get. Specifically:
There were 59 pairs of patients, using the individual game plan and the hospital mortality rate was 23.7% for ECMO patients compared with 52.5% for non-ECMO patients. The relative risk was 0.45 with a confidence interval 95% 0.26 to 0.79, which was significant at P = 0.006.
There were 75 pairs by comparing the propensity score, and mortality rates were 24% and 46.7% of patients ECMO and ECMO, respectively. The relative risk was 0.51 with a confidence interval 95% 0.31 to 0.81, which was significant at P = 0.008.
Finally, there were 75 parties identified by comparing GenMatch, and the hospital mortality rate was 24% of ECMO patients compared with 50.7% for those not receiving ECMO. The relative risk was 0.47 with a confidence interval 95% 0.31 to 0.72, which was significant at P = 0.001.
Patient characteristics used in play are defined from the outset and includes many who are expected to have an effect on the outcome, including age, degree of hypoxemia, organ dysfunction, pregnancy, obesity and use of strategies alternative ventilation, Peek and colleagues reported.
However, they warned, unobserved factors that might have affected the results. They added that the management of ECMO patients was not part of the study protocol so it can not tell if the lung-protective ventilation was used by them.
Finally, they noted, the results should be generalized with caution because, among other things, the groups of patients had some important differences.
The findings add to the results of other studies that have “revitalized interest” in ECMO as a therapeutic strategy for ARDS, according to William Checkley, MD, PhD, Johns Hopkins University.
In an accompanying editorial, Checkley said that the observed differences in mortality are just that, and suggested that it might be time for a randomized controlled trial of ECMO early in the course of ARDS.
In the UK study, noted that patients who received ECMO were treated in highly specialized, so it is difficult to “separate” treatment effect of the benefits of having highly experienced caregivers.
And down he said, ECMO is invasive, requires no anticoagulation may be associated with serious adverse effects, and can only be done in specialized environments.
Swift’s study was supported by the National Institute of Health Research. The newspaper said the money has been given informed look at his institution of the Society of Critical Care Medicine, European Society of Intensive Care, Avalon Laboratories, medical and Chalice.
Checkley is supported by the National Heart, Lung, and Blood Institute. The magazine said he had reported no disclosures.
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