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Apoyo extracorporal a la vida para adultos con insuficiencia respiratoria e indicaciones relacionadas: una revisión
Daniel Brodie1,2, Arthur S Slutsky3,4, Alain Combes5,6
1Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.
JAMA
|August 14, 2019
Resumen
El soporte vital extracorpóreo (ELS) es cada vez más aceptado para adultos con insuficiencia respiratoria aguda, impulsado por los avances tecnológicos y la creciente evidencia. ELS es ahora una opción viable para la atención crítica y el apoyo de órganos en poblaciones específicas de pacientes.
Área de la Ciencia:
- Sistemas cardiovasculares y respiratorios
- Medicina de cuidados intensivos
- Tecnología médica
Sus antecedentes:
- El uso de soporte vital extracorpóreo (ELS) en adultos con insuficiencia respiratoria aguda ha crecido, pero el entusiasmo a menudo ha superado la evidencia.
- Los ensayos clínicos anteriores en las décadas de 1970 y 1990 no demostraron el beneficio de ELS, lo que limitó su uso.
- Los avances tecnológicos han mejorado la seguridad y la eficacia del ELS.
Objetivo del estudio:
- Evaluar el papel en evolución y la aceptación del soporte vital extracorpóreo en el manejo de la insuficiencia respiratoria aguda en adultos.
- Evaluar cómo los datos recientes y las mejoras tecnológicas han influido en la práctica clínica en relación con ELS.
- Explorar las indicaciones en expansión para ELS en cuidados intensivos.
Principales métodos:
- Revisión de los ensayos clínicos históricos y su impacto en la adopción de ELS.
- Análisis de los acontecimientos clave que influyen en el interés de la ELS, incluido un ECA de 2009 y la pandemia de influenza H1N1 de 2009.
- Examen de un ECA de 2018 en ARDS grave, análisis bayesiano posterior y metanálisis.
Principales resultados:
- Los primeros ensayos no demostraron el beneficio del ELS, pero las mejoras tecnológicas mejoraron su seguridad.
- Un ECA de 2018 mostró una reducción no significativa de la mortalidad en el SDR grave, pero los análisis post hoc sugirieron un beneficio.
- ELS ahora se considera un soporte de órganos aceptable, con roles en expansión en el trasplante de pulmón y la enfermedad vascular pulmonar.
Conclusiones:
- El papel del soporte vital extracorpóreo en la insuficiencia respiratoria aguda está redefinido por el progreso tecnológico y la evidencia.
- Los desarrollos futuros del ELS se derivarán de la innovación tecnológica y de un conocimiento fisiológico más profundo.
- ELS se está convirtiendo en una parte integral del manejo de enfermedades respiratorias y cardíacas complejas.
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