Impact of Center of Admission on Receipt of Extracorporeal Membrane Oxygenation Among Patients With Hypoxemic Respiratory Failure

Bourke W. Tillmann MD, PhD , Tai Pham MD, PhD , Damon C. Scales MD, PhD , Eddy Fan MD, PhD , Ruxandra Pinto PhD , Gordon Rubenfeld MD , Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) Investigators and Réseau Européen de Recherche en Ventilation Artificielle (REVA) Registry
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引用次数: 0

Abstract

Background

Given the resources and specialized training required to deliver extracorporeal membrane oxygenation (ECMO), the provision of ECMO often is centralized within expert centers. Spurred by recent evidence, the use of ECMO has increased dramatically. However, given the centralized nature of ECMO, it is possible that inequities in access exist.

Research Question

Does center of admission impact the likelihood of receiving ECMO among adults with moderate or severe acute hypoxemic respiratory failure (Pao2 to Fio2 ratio ≤ 200 mm Hg within 48 h of ventilation).

Study Design and Methods

We performed a retrospective cohort study using data from the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) and Reseau Europeen de Recherche en Ventilation Artificielle (REVA) Influenza A(H1N1) Registry databases. Using modified log-Poisson analysis, we estimated the likelihood of receiving extracorporeal membrane oxygenation (ECMO) (initiation at the admitting hospital or transfer for initiation), adjusting for disease severity over time. To explore unmeasured confounding, we evaluated the association between center of admission on three negative controls: neuromuscular blockade, prone positioning, and dialysis.

Results

Among 1,581 patients (37.7% female patients; mean age, 60.7 years), 76 patients (4.8%) received ECMO. Longitudinal analysis, adjusted for trends in disease severity, demonstrated that patients admitted to ECMO centers were two times more likely to receive ECMO than those admitted to non-ECMO centers (relative risk [RR], 2.00; 95% CI, 1.17-3.41). Patients at ECMO centers received ECMO 2 days earlier than those at non-ECMO centers: median time to initiation was 1 day (interquartile range, 1-5 days) vs 3 days (interquartile range, 2-5 days; P = .04). Center of admission was not associated with neuromuscular blockade (RR, 1.08; 95% CI, 0.90-1.30), prone positioning (RR, 0.93; 95% CI, 0.68-1.28), or dialysis (RR, 1.04; 95% CI, 0.84-1.27).

Interpretation

Adults with hypoxemic respiratory failure admitted to ECMO centers were twice as likely to receive ECMO as those admitted to non-ECMO centers. These finding raise concerns regarding equity in access to care and suggest a potential lower threshold among clinicians at ECMO centers for initiation of ECMO.

入院中心对低氧性呼吸衰竭患者接受体外膜氧合的影响
背景鉴于提供体外膜肺氧合(ECMO)所需的资源和专业培训,ECMO 通常由专家中心集中提供。在最新证据的刺激下,ECMO 的使用急剧增加。研究问题入院中心是否会影响中度或重度急性低氧血症呼吸衰竭(通气 48 小时内 Pao2 与 Fio2 比值≤ 200 mm Hg)成人接受 ECMO 的可能性。研究设计和方法我们利用了解严重急性呼吸衰竭全球影响的大型观察研究(LUNG SAFE)和欧洲人工通气研究中心(REVA)甲型 H1N1 流感登记数据库中的数据进行了一项回顾性队列研究。通过改良对数泊松分析,我们估算了接受体外膜肺氧合(ECMO)的可能性(在入院医院开始或转院开始),并根据疾病严重程度随时间变化进行了调整。为了探究未测量的混杂因素,我们评估了入院中心与神经肌肉阻滞、俯卧位和透析这三个阴性对照之间的关联。结果在 1581 名患者(37.7% 为女性;平均年龄 60.7 岁)中,76 名患者(4.8%)接受了 ECMO。根据疾病严重程度的趋势进行调整后的纵向分析表明,ECMO 中心的患者接受 ECMO 的可能性是非 ECMO 中心患者的两倍(相对风险 [RR],2.00;95% CI,1.17-3.41)。ECMO 中心的患者比非 ECMO 中心的患者早两天接受 ECMO:中位数启动时间为 1 天(四分位数间距为 1-5 天),而非 ECMO 中心的患者为 3 天(四分位数间距为 2-5 天;P = .04)。入院中心与神经肌肉阻滞(RR,1.08;95% CI,0.90-1.30)、俯卧位(RR,0.93;95% CI,0.68-1.28)或透析(RR,1.04;95% CI,0.84-1.27)无关。这些发现引起了人们对公平就医的关注,并表明 ECMO 中心的临床医生可能会降低启动 ECMO 的门槛。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
CHEST critical care
CHEST critical care Critical Care and Intensive Care Medicine, Pulmonary and Respiratory Medicine
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