REST
Trial question
What is the effect of lower tidal volume ventilation facilitated by extracorporeal CO2 removal in patients with acute hypoxemic respiratory failure?
Study design
Multi-center
Open label
RCT
Population
Characteristics of study participants
35.0% female
65.0% male
N = 412
412 patients (143 female, 269 male)
Inclusion criteria: adult patients receiving mechanical ventilation for acute hypoxemic respiratory failure
Key exclusion criteria: receipt of invasive mechanical ventilation > 7 days, contraindication to limited systemic anticoagulation with heparin, untreated PE, pleural effusion, pneumothorax, or LV failure or fluid overload
Interventions
N=202 extracorporeal CO2 removal (lower tidal volume ventilation facilitated by extracorporeal CO2 removal for at least 48 hours)
N=210 standard care (standard care with conventional low tidal volume ventilation)
Primary outcome
Death from all causes at 90 days
41.5
39.5
41.5 %
31.1 %
20.8 %
10.4 %
0.0 %
Extracorporeal carbon dioxide
removal
Standard
care
No significant
difference ↔
No significant difference in death from all causes at 90 days (41.5% vs. 39.5%; RR 1.05, 95% CI 0.83 to 1.33)
Secondary outcomes
Significant decrease in ventilator-free days (7.1 days vs. 9.2 days; AD -2.1 days, 95% CI -3.8 to -0.3)
No significant difference in the rate of need for ECMO to day 7 (6% vs. 3%; RR 2.08, 95% CI 0.8 to 5.43)
No significant difference in death at day 28 (38% vs. 36%; RR 1.06, 95% CI 0.82 to 1.37)
Safety outcomes
No significant differences in duration of ventilation, adverse events.
Conclusion
In adult patients receiving mechanical ventilation for acute hypoxemic respiratory failure, extracorporeal CO2 removal was not superior to standard care with respect to death from all causes at 90 days.
Reference
James J McNamee, Michael A Gillies, Nicholas A Barrett et al. Effect of Lower Tidal Volume Ventilation Facilitated by Extracorporeal Carbon Dioxide Removal vs Standard Care Ventilation on 90-Day Mortality in Patients With Acute Hypoxemic Respiratory Failure: The REST Randomized Clinical Trial. JAMA. 2021 Sep 21;326(11):1013-1023.
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