Comparisons of Outcomes between Patients with Direct and Indirect Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design and Patient Inclusion
2.2. Definitions
2.3. Data Collection
2.4. Statistical Analysis
3. Results
3.1. Study Patients
3.2. Comparisons of Direct and Indirect ARDS Patients
3.3. Clinical Outcomes of Direct and Indirect ARDS Patients
3.4. Comparison of Direct and Indirect ARDS Patients in Terms of Survival
3.5. Factors Associated with Hospital Mortality in Cases of Direct and Indirect ARDS
3.6. Comparisons of Direct and Indirect ARDS Patients after Excluding VA ECMO Patients
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Variables | All | Direct ARDS | Indirect ARDS | p |
---|---|---|---|---|
(n = 152) | (n = 118) | (n = 34) | ||
Age (years) | 50.3 ± 16.4 | 50.8 ± 16.3 | 48.5 ± 16.6 | 0.463 |
Gender (male) | 103 (67.8%) | 83 (70.3%) | 20 (58.8%) | 0.206 |
Body mass index (kg/m2) | 25.8 ± 5.3 | 25.9 ± 5.4 | 25.5 ± 4.8 | 0.766 |
Diabetes mellitus | 40 (26%) | 33 (28%) | 7 (20.6%) | 0.389 |
Chronic liver disease | 21 (14%) | 16 (13.6%) | 5 (14.7%) | 0.864 |
Immunocompromised status | 40 (26%) | 28 (23.7%) | 12 (35.3%) | 0.177 |
Chronic kidney disease | 17 (11.2%) | 13 (11%) | 4 (11.8%) | 1.000 |
SOFA score before ECMO | 10.8 ± 3.2 | 10.6 ± 3.0 | 11.5 ± 3.4 | 0.154 |
Lung injury score before ECMO | 3.4 ± 0.4 | 3.4 ± 0.4 | 3.3 ± 0.4 | 0.036 |
ARDS duration before ECMO (h) | 28 (7–122) | 29 (7–122) | 24 (5–192) | 0.306 |
pH before ECMO | 7.28 ± 0.14 | 7.28 ± 0.14 | 7.26 ± 0.13 | 0.494 |
PaCO2 (mm Hg) before ECMO | 52.5 ± 19.0 | 52.6 ± 19.2 | 51.9 ± 18.6 | 0.848 |
PaO2/FiO2 (mm Hg) before ECMO | 63 (52–88) | 63 (52–87) | 65 (53–97) | 0.430 |
Ventilator settings before ECMO | ||||
Mechanical power (J/min) | 23.8 ± 9.6 | 24.7 ± 9.5 | 20.5 ± 9.4 | 0.023 |
Tidal volume (mL/kg PBW) | 7.7 ± 2.4 | 7.7 ± 2.3 | 7.7 ± 2.9 | 0.981 |
PEEP (cm H2O) | 12.0 ± 2.8 | 12.2 ± 2.8 | 11.3 ± 2.8 | 0.106 |
Peak inspiratory pressure (cm H2O) | 33.9 ± 6.5 | 34.2 ± 6.5 | 33.2 ± 6.6 | 0.457 |
Mean airway pressure (cm H2O) | 18.6 ± 4.4 | 19.0 ± 4.4 | 17.5 ± 4.4 | 0.094 |
Dynamic compliance (mL/cm H2O) | 22.6 ± 11.3 | 22.8 ± 11.2 | 21.8 ± 11.8 | 0.680 |
Minute ventilation (L/min) | 10.6 ± 3.8 | 11.0 ± 3.9 | 9.2 ± 3.3 | 0.019 |
Ventilatory ratio | 2.5 ± 1.1 | 2.5 ± 1.0 | 2.3 ± 1.2 | 0.183 |
ECMO venoarterial mode | 24 (15.8%) | 14 (11.9%) | 10 (29.4%) | 0.013 |
SOFA score from day 1 to day 3 on ECMO | 9.6 ± 2.3 | 9.4 ± 2.2 | 10.6 ± 2.3 | 0.015 |
pH from day1 to day 3 on ECMO | 7.43 ± 0.08 | 7.44 ± 0.08 | 7.42 ± 0.08 | 0.146 |
PaCO2 (mm Hg) from day1 to day 3 on ECMO | 38.2 ± 5.3 | 38.2 ± 5.1 | 38.2 ± 6.1 | 0.999 |
PaO2/FiO2 (mm Hg) from day 1 to day 3 on ECMO | 178 (131–240) | 167 (130–224) | 194 (150–248) | 0.857 |
Ventilator settings from day 1 to day 3 on ECMO | ||||
Mechanical power (J/min) | 12.1 ± 6.2 | 12.0 ± 6.2 | 12.3 ± 6.7 | 0.867 |
Tidal volume (mL/kg PBW) | 6.0 ± 2.2 | 6.1 ± 2.1 | 5.9 ± 2.7 | 0.705 |
PEEP (cm H2O) | 12.0 ± 3.3 | 12.4 ± 3.4 | 10.7 ± 2.5 | 0.008 |
Peak inspiratory pressure (cm H2O) | 31.7 ± 5.6 | 31.6 ± 5.9 | 32.2 ± 4.8 | 0.596 |
Mean airway pressure (cm H2O) | 17.7 ± 4.0 | 17.9 ± 4.3 | 17.0 ± 2.9 | 0.196 |
Dynamic compliance (mL/cm H2O) | 19.2 ± 8.1 | 19.7 ± 7.7 | 17.4 ± 9.3 | 0.153 |
Minute ventilation (L/min) | 5.7 ± 2.8 | 5.6 ± 2.7 | 5.8 ± 3.1 | 0.679 |
Fluid balance, ml | ||||
Before ECMO | 923 (−258 to 2125) | 884 (−193 to 2145) | 1125 (−486 to 2094) | 0.836 |
Cumulative 3 days | 1190 (−873 to 3935) | 947 (−1355 to 3253) | 1844 (−208 to 5679) | 0.046 |
Inotropes (n) | 133 (87.5%) | 102 (86.4%) | 31 (91.2%) | 0.568 |
Outcomes | Direct ARDS | Indirect ARDS | p |
---|---|---|---|
(n = 118) | (n = 34) | ||
Mortality | |||
28 day hospital mortality, n (%) | 41 (34.7%) | 20 (58.8%) | 0.005 |
60 day hospital mortality, n (%) | 53 (44.9%) | 21 (61.8%) | 0.025 |
90 day hospital mortality, n (%) | 56 (47.5%) | 21 (61.8%) | 0.041 |
Other outcomes | |||
Duration of ECMO (days) | 10 (6–16) | 7 (4–11) | 0.044 |
Duration of mechanical ventilator (days) | 22 (12–40) | 18 (10–34) | 0.201 |
Length of ICU stay (days) | 25 (15–46) | 22 (11–38) | 0.191 |
Length of hospital stay (days) | 42 (22–65) | 33 (19–68) | 0.626 |
ECMO-free days at day 28 | 0 (0–9) | 0 (0–19) | 0.126 |
Ventilator–free days on day 28 | 0 (0–9) | 0 (0–0) | 0.135 |
Ventilator–free days on day 60 | 0 (0–41) | 0 (0–30) | 0.145 |
Variables | Direct ARDS (n = 118) | Indirect ARDS (n = 34) | ||||
---|---|---|---|---|---|---|
Survivors | Non-Survivors | p | Survivors | Non-Survivors | p | |
(n = 59) | (n = 59) | (n = 12) | (n = 22) | |||
Age (years) | 47.3 ± 15.7 | 54.4 ± 16.3 | 0.017 | 39.8 ± 19.3 | 53.2 ± 13.1 | 0.022 |
Gender (male) | 40 (67.8%) | 43 (72.9%) | 0.545 | 8 (66.7%) | 12 (54.5%) | 0.717 |
Body mass index (kg/m2) | 26.4 ± 6.1 | 25.3 ± 4.7 | 0.292 | 24.1 ± 4.2 | 26.5 ± 5.1 | 0.218 |
Diabetes mellitus | 21 (35.6%) | 12 (20.3%) | 0.065 | 2 (16.7%) | 5 (22.7%) | 1.000 |
Chronic liver disease | 6 (10.2%) | 10 (16.9%) | 0.282 | 0 | 5 (22.7%) | 0.137 |
Immunocompromised status | 8 (13.6%) | 20 (33.9%) | 0.009 | 3 (25%) | 9 (40.9%) | 0.465 |
Chronic kidney disease | 8 (13.6%) | 5 (8.5%) | 0.378 | 0 | 4 (18.2%) | 0.273 |
SOFA score before ECMO | 10.4 ± 3.0 | 10.8 ± 3.1 | 0.509 | 9.8 ± 3.2 | 12.5 ± 3.2 | 0.024 |
Lung injury score before ECMO | 3.5 ± 0.4 | 3.3 ± 0.5 | 0.055 | 3.2 ± 0.6 | 3.3 ± 0.4 | 0.554 |
ARDS duration before ECMO (h) | 10 (5–70) | 63 (16–154) | 0.003 | 6 (1–34) | 38 (16–355) | 0.018 |
pH before ECMO | 7.28 ± 0.13 | 7.28 ± 0.15 | 0.731 | 7.26 ± 0.09 | 7.26 ± 0.16 | 0.989 |
PaCO2 (mm Hg) before ECMO | 51.6 ± 21.0 | 53.6 ± 17.4 | 0.572 | 46.3 ± 9.9 | 54.9 ± 21.5 | 0.117 |
PaO2/FiO2 (mm Hg) before ECMO | 61 (50–77) | 64 (52–107) | 0.083 | 75 (60–101) | 57 (51–98) | 0.495 |
Ventilator settings before ECMO | ||||||
Mechanical power (J/min) | 24.8 ± 10.5 | 24.6 ± 8.5 | 0.877 | 20.5 ± 8.8 | 20.4 ± 9.8 | 0.974 |
Tidal volume (mL/kg PBW) | 7.7 ± 2.3 | 7.8 ± 2.3 | 0.722 | 7.6 ± 2.6 | 7.8 ± 3.1 | 0.791 |
PEEP (cm H2O) | 12.4 ± 2.5 | 11.9 ± 3.1 | 0.343 | 11.3 ± 2.8 | 11.3 ± 2.8 | 0.952 |
Peak inspiratory pressure (cm H2O) | 33.7 ± 5.9 | 34.6 ± 7.1 | 0.481 | 33.3 ± 7.1 | 33.2 ± 6.5 | 0.978 |
Mean airway pressure (cm H2O) | 18.7 ± 4.1 | 19.2 ± 4.7 | 0.587 | 16.9 ± 4.3 | 17.9 ± 4.5 | 0.554 |
Dynamic compliance (mL/cm H2O) | 24.1 ± 12.2 | 21.4 ± 10.0 | 0.207 | 19.9 ± 6.9 | 23.1 ± 14.1 | 0.469 |
Minute ventilation (L/min) | 10.9 ± 4.2 | 11.0 ± 3.5 | 0.837 | 9.5 ± 3.1 | 9.1 ± 3.5 | 0.740 |
Ventilatory ratio | 2.4 ± 1.0 | 2.6 ± 1.1 | 0.280 | 2.0 ± 0.8 | 2.4 ± 1.4 | 0.350 |
ECMO venoarterial mode | 4 (6.8%) | 10 (16.9%) | 0.153 | 2 (16.7%) | 8 (36.4%) | 0.432 |
SOFA score from day 1 to day 3 on ECMO | 8.8 ± 1.8 | 10.1 ± 2.4 | 0.001 | 9.5 ± 2.1 | 11.3 ± 2.3 | 0.060 |
pH from day1 to day 3 on ECMO | 7.46 ± 0.06 | 7.42 ± 0.09 | 0.006 | 7.45 ± 0.08 | 7.40 ± 0.08 | 0.138 |
PaCO2 (mm Hg) from day1 to day 3 on ECMO | 38.2 ± 4.9 | 38.2 ± 5.3 | 0.960 | 37.4 ± 5.5 | 38.6 ± 6.4 | 0.586 |
PaO2/FiO2 (mm Hg) from day 1 to day 3 on ECMO | 194 (145–247) | 151 (122–203) | 0.844 | 224 (171–287) | 184 (134–237) | 0.313 |
Ventilator settings from day 1 to day 3 on ECMO | ||||||
Mechanical power (J/min) | 11.2 ± 4.4 | 12.9 ± 7.4 | 0.136 | 9.4 ± 3.4 | 13.8 ± 7.5 | 0.026 |
volume (mL/kg PBW) | 6.0 ± 2.0 | 6.1 ± 2.1 | 0.878 | 6.1 ± 2.1 | 5.8 ± 3.0 | 0.716 |
PEEP (cm H2O) | 12.7 ± 3.2 | 12.0 ± 3.5 | 0.299 | 10.7 ± 2.7 | 10.7 ± 2.5 | 0.989 |
Peak inspiratory pressure (cm H2O) | 30.8 ± 5.1 | 32.4 ± 6.5 | 0.148 | 29.4 ± 5.4 | 33.7 ± 3.8 | 0.011 |
Mean airway pressure (cm H2O) | 17.7 ± 3.8 | 18.1 ± 4.7 | 0.587 | 16.1 ± 2.4 | 17.5 ± 3.1 | 0.173 |
Dynamic compliance (mL/cm H2O) | 21.1 ± 7.6 | 18.3 ± 7.6 | 0.055 | 21.2 ± 8.8 | 13.6 ± 7.2 | 0.015 |
Minute ventilation (L/min) | 5.3 ± 2.1 | 5.9 ± 3.1 | 0.224 | 4.9 ± 1.9 | 6.4 ± 3.5 | 0.116 |
Fluid balance, ml | ||||||
Before ECMO | 991 (−262 to 2278) | 795 (−167 to 1723) | 0.983 | 1641 (−753 to 2951) | 951 (−486 to 1880) | 0.535 |
Cumulative 3 days | −29 (−1831 to 2108) | 2051(−441 to 4534) | 0.001 | 1971 (−708 to 3828) | 1803 (77–7267) | 0.238 |
Inotropes (n) | 43 (72.9%) | 59 (100%) | <0.001 | 10 (83.3%) | 21 (95.5%) | 0.279 |
Variables | Direct ARDS (n = 118) | Indirect ARDS (n = 34) | ||
---|---|---|---|---|
Adjust HR (95% CI) | p | Adjust HR (95% CI) | p | |
Diabetes mellitus | 0.246 (0.111–0.546) | 0.001 | ||
Immunocompromised status | 3.860 (1.943–7.668) | <0.001 | ||
ARDS duration before ECMO (h) | 1.002 (1.000–1.004) | 0.015 | ||
SOFA score from day 1 to day 3 on ECMO | 1.225 (1.070–1.402) | 0.003 | 2.514 (1.474–4.286) | 0.001 |
Dynamic compliance from day 1 to day 3 on ECMO | 0.886 (0.802–0.978) | 0.017 |
Variables | All | Direct ARDS | Indirect ARDS | p |
---|---|---|---|---|
(n = 128) | (n = 104) | (n = 24) | ||
Age (years) | 51.2 ± 16.5 | 51.1 ± 16.6 | 51.3 ± 16.5 | 0.975 |
Gender (male) | 89 (69.5%) | 72 (69.2%) | 17 (70.8%) | 0.878 |
Body mass index (kg/m2) | 25.8 ± 5.5 | 25.9 ± 5.6 | 25.4 ± 4.7 | 0.708 |
Diabetes mellitus | 38 (29.7%) | 31 (29.8%) | 7 (29.2%) | 0.951 |
Chronic liver disease | 20 (15.6%) | 16 (15.4%) | 4 (16.7%) | 1.000 |
Immunocompromised status | 34 (26.6%) | 25 (24%) | 9 (37.5%) | 0.178 |
Chronic kidney disease | 16 (12.5%) | 12 (11.5%) | 4 (16.7%) | 0.500 |
SOFA score before ECMO | 10.7 ± 3.1 | 10.5 ± 3.1 | 11.7 ± 2.8 | 0.091 |
Lung injury score before ECMO | 3.4 ± 0.4 | 3.4 ± 0.4 | 3.2 ± 0.4 | 0.041 |
ARDS duration before ECMO (h) | 29 (8–133) | 29 (8–122) | 30 (8–339) | 0.143 |
pH before ECMO | 7.28 ± 0.14 | 7.29 ± 0.14 | 7.24 ± 0.13 | 0.186 |
PaCO2 (mm Hg) before ECMO | 52.8 ± 19.5 | 52.7 ± 19.3 | 53.5 ± 20.6 | 0.851 |
PaO2/FiO2 (mm Hg) before ECMO | 63 (52–93) | 63 (52–86) | 65 (54–107) | 0.216 |
Ventilator settings before ECMO | ||||
Mechanical power (J/min) | 24.1 ± 9.8 | 24.7 ± 9.7 | 21.5 ± 9.8 | 0.152 |
Tidal volume (mL/kg PBW) | 7.7 ± 2.3 | 7.7 ± 2.3 | 7.8 ± 2.2 | 0.948 |
PEEP (cm H2O) | 12.2 ± 2.7 | 12.3 ± 2.7 | 11.5 ± 2.5 | 0.180 |
Peak inspiratory pressure (cm H2O) | 33.9 ± 6.5 | 34.0 ± 6.2 | 33.6 ± 7.5 | 0.772 |
Mean airway pressure (cm H2O) | 18.6 ± 4.4 | 18.8 ± 4.4 | 17.8 ± 4.7 | 0.331 |
Dynamic compliance (mL/cm H2O) | 22.8 ± 11.3 | 22.7 ± 11.0 | 23.1 ± 13.1 | 0.874 |
Minute ventilation (L/min) | 10.7 ± 3.9 | 11.0 ± 4.1 | 9.4 ± 3.1 | 0.089 |
Ventilatory ratio | 2.5 ± 1.0 | 2.5 ± 1.0 | 2.3 ± 1.2 | 0.426 |
SOFA score from day 1 to day 3 on ECMO | 9.7 ± 2.2 | 9.5 ± 2.1 | 11.0 ± 2.1 | 0.005 |
pH from day1 to day 3 on ECMO | 7.44 ± 0.07 | 7.44 ± 0.07 | 7.41 ± 0.08 | 0.083 |
PaCO2 (mm Hg) from day1 to day 3 on ECMO | 38.1 ± 5.0 | 38.0 ± 4.9 | 38.6 ± 5.4 | 0.576 |
PaO2/FiO2 (mm Hg) from day 1 to day 3 on ECMO | 178 (134–216) | 167 (131–214) | 194 (156–240) | 0.763 |
Ventilator settings from day 1 to day 3 on ECMO | ||||
Mechanical power (J/min) | 11.7 ± 6.1 | 11.5 ± 6.0 | 12.2 ± 6.2 | 0.638 |
Tidal volume (mL/kg PBW) | 5.9 ± 2.0 | 5.9 ± 2.1 | 5.6 ± 1.8 | 0.537 |
PEEP (cm H2O) | 12.3 ± 3.3 | 12.6 ± 3.4 | 10.8 ± 2.5 | 0.017 |
Peak inspiratory pressure (cm H2O) | 31.3 ± 5.3 | 31.2 ± 5.3 | 32.0 ± 5.2 | 0.467 |
Mean airway pressure (cm H2O) | 17.7 ± 3.9 | 17.9 ± 4.2 | 17.2 ± 2.7 | 0.325 |
Dynamic compliance (mL/cm H2O) | 19.3 ± 7.9 | 19.7 ± 7.6 | 17.6 ± 9.3 | 0.269 |
Minute ventilation (L/min) | 5.5 ± 2.8 | 5.4 ± 2.7 | 5.8 ± 2.9 | 0.556 |
Fluid balance, ml | ||||
Before ECMO | 938 (−130 to 2125) | 938 (−78 to 2204) | 957 (−717 to 2002) | 0.731 |
Cumulative 3 days | 1190 (−873 to 3846) | 801 (−1378 to 3275) | 2097 (1100 to 6976) | 0.029 |
Inotropes (n) | 111 (89.5%) | 89 (85.6%) | 22 (91.7%) | 0.738 |
28 day hospital mortality, n (%) | 48 (37.5%) | 34 (32.7%) | 14 (58.3%) | 0.009 |
60 day hospital mortality, n (%) | 57 (44.5%) | 42 (40.4%) | 15 (62.5%) | 0.019 |
90 day hospital mortality, n (%) | 59 (46.1%) | 44 (42.3%) | 15 (62.5%) | 0.027 |
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Chiu, L.-C.; Chuang, L.-P.; Lin, S.-W.; Li, H.-H.; Leu, S.-W.; Chang, K.-W.; Huang, C.-H.; Chiu, T.-H.; Wu, H.-P.; Tsai, F.-C.; et al. Comparisons of Outcomes between Patients with Direct and Indirect Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation. Membranes 2021, 11, 644. https://doi.org/10.3390/membranes11080644
Chiu L-C, Chuang L-P, Lin S-W, Li H-H, Leu S-W, Chang K-W, Huang C-H, Chiu T-H, Wu H-P, Tsai F-C, et al. Comparisons of Outcomes between Patients with Direct and Indirect Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation. Membranes. 2021; 11(8):644. https://doi.org/10.3390/membranes11080644
Chicago/Turabian StyleChiu, Li-Chung, Li-Pang Chuang, Shih-Wei Lin, Hsin-Hsien Li, Shaw-Woei Leu, Ko-Wei Chang, Chi-Hsien Huang, Tzu-Hsuan Chiu, Huang-Pin Wu, Feng-Chun Tsai, and et al. 2021. "Comparisons of Outcomes between Patients with Direct and Indirect Acute Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation" Membranes 11, no. 8: 644. https://doi.org/10.3390/membranes11080644