• Sachin Sud, Eddy Fan, AdhikariNeill K JNKJInterdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.Department of Critical Care Medicine, Sunnybrook, Jan O Friedrich, Niall D Ferguson, Alain Combes, Claude Guerin, and Gordon Guyatt.
• Division of Critical Care, Department of Medicine, Trillium Health Center, University of Toronto, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada. sachinsud@aol.com.
• Intensive Care Med. 2024 Jul 1; 50 (7): 102110341021-1034.

PurposeSevere acute respiratory distress syndrome (ARDS) with PaO2/FiO2 < 80 mmHg is a life-threatening condition. The optimal management strategy is unclear. The aim of this meta-analysis was to compare the effects of low tidal volumes (Vt), moderate Vt, prone ventilation, and venovenous extracorporeal membrane oxygenation (VV-ECMO) on mortality in severe ARDS.MethodsWe performed a frequentist network meta-analysis of randomised controlled trials (RCTs) with participants who had severe ARDS and met eligibility criteria for VV-ECMO or had PaO2/FiO2 < 80 mmHg. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to discern the relative effect of interventions on mortality and the certainty of the evidence.ResultsTen RCTs including 812 participants with severe ARDS were eligible. VV-ECMO reduces mortality compared to low Vt (risk ratio [RR] 0.77, 95% confidence interval [CI] 0.59-0.99, moderate certainty) and compared to moderate Vt (RR 0.75, 95% CI 0.57-0.98, low certainty). Prone ventilation reduces mortality compared to moderate Vt (RR 0.78, 95% CI 0.66-0.93, high certainty) and compared to low Vt (RR 0.81, 95% CI 0.63-1.02, moderate certainty). We found no difference in the network comparison of VV-ECMO compared to prone ventilation (RR 0.95, 95% CI 0.72-1.26), but inferences were based solely on indirect comparisons with very low certainty due to very wide confidence intervals.ConclusionsIn adults with ARDS and severe hypoxia, both VV-ECMO (low to moderate certainty evidence) and prone ventilation (moderate to high certainty evidence) improve mortality relative to low and moderate Vt strategies. The impact of VV-ECMO versus prone ventilation remains uncertain.© 2024. Springer-Verlag GmbH Germany, part of Springer Nature.

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