The use of ECMO for ARDS in the United States: trends and patient characteristics
CCCF ePoster library. Rush B. Oct 26, 2015; 117326; P4
Barret Rush
Barret Rush
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Abstract
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P4


Topic: Retrospective or Prospective Cohort Study


The use of ECMO for ARDS in the United States: trends and patient characteristics



Barret Rush, K. Wiskar, L. Berger, D. Griesdale

Critical Care, UBC, Vancouver, Canada | Department of Medicine, UBC, Vancouver, Canada | Anesthesia, UBC, Vancouver, Canada | Critical Care Medicine and Anesthesiology, UBC, Vancouver, Canada

Introduction:

The acute respiratory distress syndrome (ARDS) continues to cause a high mortality despite advances in critical care.1–3 To date, the only interventions in ARDS that have been shown to improve survival are prone positioning and low tidal volume ventilation. 4–7 In addition to these interventions, extra-corporeal membrane oxygenation (ECMO) has received increasing attention in the past decade. The 2014 Extra-corporeal Life Support Organization (ELSO) guidelines suggest that ECMO be considered in patients with high-risk hypoxic or hypercarbic respiratory failure despite optimal conventional ventilation.8



Objectives: Our aim was to describe patient characteristics and trends in the use of ECMO for the treatment of ARDS in the United States from 2006-2011.

Methods:

We used the Nationwide Inpatient Sample (NIS) to isolate all patients ≥18 years of age who had a discharge ICD9 diagnosis of ARDS9, with and without procedure codes for ECMO, between 2006 and 2011. Released by the Agency for Healthcare Research and Quality (AHRQ), the NIS captures approximately twenty percent of US hospital discharges and allows estimation of national rates and proportions.

Patient level factors included age, gender, race (White, Black, Hispanic, other or missing), length of stay, hospital mortality, insurance status (coverage vs no coverage), time to initiate ECMO, and income quartile according to zip code. Hospital characteristics included teaching status (teaching vs non-teaching), size (as defined by the AHRQ10), and region (Northeast, Midwest, South, West).

We performed Chi-squared tests to analyze nominal or ordinal outcomes. Independent t-tests were used to analyze normally distributed continuous variables. Linear regression was utilized to determine statistically significant trends in the rates of ECMO measured across years.



Results:

We examined a total of 47,911,414 hospital discharges, representing 235,911,271 hospitalizations using national weights. Of the 1,479,022 patients meeting the definition of ARDS (representing 7,281,206 discharges), 775 underwent ECMO (Table 1). There was a 409% relative increase in the use of ECMO for ARDS in the United States between 2006 and 2011, from 0.0178% to 0.090% (p=0.0041) (Figure 1).

Patients treated with ECMO had higher in-hospital mortality (58.6% vs 25.1%, p<0.0001) and longer hospital stays (15.8 days vs 6.9 days, p<0.0001). They were also younger (47.9 vs 66.4 years, p<0.0001), more likely to be male (62.2% vs 49.6%, p<0.0001), and more likely to receive inhaled nitric oxide (2.4% vs 0.02%, p<0.0001). Patients receiving ECMO were also less likely to have medical insurance (89.7% vs 92.3%, p=0.03). Hospital characteristics associated with the use of ECMO included teaching status (92.0% vs 45.6% p<0.0001) and large size (86.7% vs 64.9% p<0.0001). The median time to initiate ECMO from the time of admission was 0.5 days (IQR 4.9 days). There was no association of the use of ECMO with zip code income quartile or region of the country.



Conclusion: There has been a dramatic increase in ECMO use for the treatment of ARDS in the United States. Patients receiving ECMO have higher mortality and tend be younger, male, and treated in large teaching hospitals. These findings are consistent with the ELSO registry data. However, these results extend beyond the ELSO registry to represent the entire US population as many ECMO centers do not contribute data to ELSO.

References:

1. Rubenfeld GD, Herridge MS. Epidemiology and outcomes of acute lung injury. Chest 2007;131(2):554–62.

2. Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence and outcomes of acute lung injury. N Engl J Med 2005;353(16):1685–93.

3. Zambon M, Vincent J-L. Mortality rates for patients with acute lung injury/ARDS have decreased over time. Chest 2008;133(5):1120–7.

4. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000;342(18):1301–8.

5. Ferguson ND, Cook DJ, Guyatt GH, et al. High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med 2013;368(9):795–805.

6. Guérin C, Reignier J, Richard J-C, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368(23):2159–68.

7. Steinberg KP, Hudson LD, Goodman RB, et al. Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome. N Engl J Med 2006;354(16):1671–84.

8. Extracorporeal Life Support Organization. Guidelines for Adult Respiratory Failure [Internet]. 2013 [cited 2015 Aug 31];Available from: https://www.elso.org/Portals/0/IGD/Archive/FileManager/989d4d4d14cusersshyerdocumentselsoguidelinesforadultrespiratoryfailure1.3.pdf

9. Reynolds H, McCunn M, Borg U, Habashi N, Cottingham C, Bar-Lavi Y. Acute respiratory distress syndrome: estimated incidence and mortality rate in a 5 million-person population base. Crit Care 1998;2(1):29–34.

10. INTRODUCTION TO THE HCUP NATIONWIDE INPATIENT SAMPLE (NIS) [Internet]. Available from: https://www.hcup-us.ahrq.gov/db/nation/nis/NIS_Introduction_2011.pdf

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