Use of extracorporeal membrane oxygenation in traumatic injuries with acute respiratory distress syndrome: A systematic review and meta-analysis

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is increasingly used in severe acute respiratory distress syndrome (ARDS) when conventional mechanical ventilation (CMV) fails. While large trials such as Conventional ventilatory Support vs Extracorporeal membrane oxygenation for Severe Adult Respiratory failure and Extracorporeal membrane Oxygenation for Severe Acute Respiratory Distress Syndrome have demonstrated ECMO's benefit in general ARDS, trauma-induced ARDS remains underrepresented. This systematic review and meta-analysis aimed to assess ECMO's efficacy and safety compared with CMV in adult trauma patients with ARDS. METHODS: We systematically searched PubMed, Embase, and Cochrane Central from inception to March 2025 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible studies included adult trauma patients with ARDS treated with ECMO (venovenous or venoarterial) versus CMV. The primary outcome was mortality; secondary outcomes included complications, ventilator-associated pneumonia, duration of mechanical ventilation, hospital length of stay (LOS), and intensive care unit (ICU) LOS. Risk of bias was assessed using the Risk of Bias in Nonrandomized Studies of Interventions tool. RESULTS: Four observational cohort studies involving 1,526 patients (ECMO, 179; CMV, 1,347) were included. Extracorporeal membrane oxygenation was associated with significantly lower mortality (odds ratio, 0.29; 95% confidence interval [CI], 0.14-0.62; p = 0.001), with an even greater benefit in the venovenous ECMO subgroup (odds ratio, 0.19; 95% CI, 0.07-0.53; p = 0.002). Extracorporeal membrane oxygenation recipients had significantly longer ICU stays (standardized mean difference, 1.54; 95% CI, 0.97-2.12; p < 0.01), but no significant differences were found in total complications, ventilator-associated pneumonia, or hospital LOS. CONCLUSION: Extracorporeal membrane oxygenation appears to reduce mortality in adult trauma-induced ARDS but is associated with prolonged ICU stay and substantial resource demands. Given the limitations of observational data, variable selection criteria, and heterogeneity across studies, these findings remain hypothesis generating. Prospective trauma-specific studies are needed to confirm the benefit and guide optimal use. LEVEL OF EVIDENCE: Systematic Review and Meta-analysis; Level IV.