Plain English Summary
Background and study aims
The researchers running this study want to test a new way of treating respiratory failure. When people are very ill their lungs often stop working. This is called respiratory failure. As a result, breathing becomes difficult and they need to be treated in an intensive care unit (ICU) where they will be connected to a machine to help their breathing. This is called mechanical ventilation. Respiratory failure is common in the UK; about 100,000 people each year need treatment with mechanical ventilation. Almost half of these patients die. Although there is evidence that mechanical ventilation does save lives, it can be linked with damage to the lungs. A mechanical ventilator acts like bellows as air is forced into the lungs under pressure. If the pressure needed to help the patient breathe is too high this can cause lung damage. New devices are now available to help patients breathe. These devices help remove carbon dioxide from the patient’s blood, which is one of the main functions of the lungs. This may allow more gentle mechanical ventilation. This more gentle ventilation may cause less harm to the lungs and improve the outcome of patients with respiratory failure. These new devices involve a tube called a catheter being placed in a large blood vessel called a vein. Blood passes from the patient through the device where it is “washed” to remove carbon dioxide before it is returned to the patient. This is called extracorporeal carbon dioxide removal. Kidney dialysis uses very similar equipment. Kidney dialysis is common for patients admitted to intensive care units and doctors are used to putting this type of catheter into patients on the ICU. These new devices may help doctors and nurses care for patients with respiratory failure, but there is not enough information about the devices to help them decide whether they are helpful or not. This study investigates whether they work or not.
Who can participate?
Patients aged at least 16 with respiratory failure and have been admitted to an intensive care unit (ICU).
What does the study involve?
Patients are randomly allocated to one of two groups. Those in group 1 are given the best level of care that is advised by current NHS guidelines. Those in group 2 also receive the best level of care but are, in addition, also treated with the device to remove carbon dioxide from their blood to allow the pressure in their lungs to be reduced. The treatment a patient receives is decided at random by a computer programme and at the end of the study researchers will know whether this new device reduces death from respiratory failure and look at the long-term survival and quality of life of the patients in the study. The cost of using the new device compared to usual care is also investigated.
What are the possible benefits and risks of participating?
Taking part in this study may have contributed to improved treatment of patients with acute respiratory failure in the future. ECCO2R is a procedure that is used in the UK in patients who have respiratory failure. A previous study found ECCO2R was well tolerated and associated with few side effects (about one in every 40 patients); however all procedures have potential side effects. Side effects of ECCO2R include complications with catheter placement such as blood vessel damage, dislodgement, infection and an increased risk of bleeding. Catheter insertion is similar to other tubes that are placed in the neck or groin veins during any ICU admission with respiratory failure and carry the same level of risk. To minimise such risks, the catheter is inserted with the help of ultrasound. Ultrasound is a medical test that uses soundwaves to capture live images from the inside of the body; this helped the doctor to directly see the blood vessel and ensure a more accurate insertion of the catheter. The potential complications whilst ECCO2R is running are uncommon and include clot formation within the device or the blood vessel (reduced by anticoagulation) or air entrainment into the device (reduced by safety mechanisms within the device). Bleeding can also occur in any patient placed on blood thinning agents (anticoagulation) and although uncommon (less than one in every 50 patients) can be significant, requiring blood transfusion and can potentially lead to serious bleeding. To minimise this risk of bleeding we regularly measured the effect of blood thinning agents on the ability of the blood to clot. All participants in the trial are monitored to ensure that any side effects are promptly picked up. ECCO2R would be stopped if they occur.
Where is the study run from?
The study is run in many ICUs in NHS hospitals in the UK.
When is the study starting and how long is it expected to run for?
June 2016 to August 2021
Who is funding the study?
National Institute for Health Research (UK)
Who is the main contact?
Miss Colette Jackson
REST@nictu.hscni.net
Trial website
Contact information
Type
Public
Primary contact
Miss Colette Jackson
ORCID ID
http://orcid.org/0000-0001-7814-0749
Contact details
NICTU
1st Floor Elliott Dynes Building
Royal Hospitals
Grosvenor Road
Belfast
BT12 6BA
United Kingdom
00 44 (0) 28 90635794
REST@nictu.hscni.net
Additional identifiers
EudraCT number
2015-005280-17
ClinicalTrials.gov number
NCT02654327
Protocol/serial number
15084DMcA-AS
Study information
Scientific title
PRotective vEntilation with veno-venouS lung assisT in respiratory failure
Acronym
The REST Trial
Study hypothesis
In adult patients who require invasive mechanical ventilation for acute hypoxaemic respiratory failure, VV-ECCO2R and lower tidal volume ventilation results in reduced mortality.
Ethics approval
Current ethics approval as of 23/05/2017:
1. South Berkshire REC England, Wales and Northern Ireland, 14/03/2016, ref: 16/SC/0089
2. Scotland A REC, Scotland, 23/03/2016, ref:16/SS/0048
Previous ethics approval:
Office of Research Ethics Committees Northern Ireland, 14/03/2016 (England and Wales)
Study design
Randomised, allocation concealed, controlled, open, pragmatic clinical and cost effectiveness trial
Primary study design
Interventional
Secondary study design
Randomised controlled trial
Trial setting
Hospitals
Trial type
Other
Patient information sheet
See additional files
Condition
Acute hypoxaemic respiratory failure
Intervention
Current interventions as of 05/03/2019:
Intervention treatment will last for up to 7 days, patient follow up will be for 12 months.
INTERVENTION ARM: A dual lumen catheter will be inserted into a central vein and veno-venous extracorpoeal carbon dioxide removal (vv-ECCO2R) initiated within 8-24 hours of consent. The pump blood flow rate and gas flow through the vv-ECCO2R device will be set up according to study manual. Thereafter tidal volumes on mechanical will be gradually decreased to approximately 3ml/kg predicted body weight, maintaining arterial pH of greater than 7.2 and plateau pressure less than or equal to 25cm H2O. A heparin infusion is used as anticoagulation to prevent circuit clotting. vv-ECCO2R will be considered for weaning after a minimum of 48 hours when weaning criteria are achieved.
CONTROL ARM: Standard management of acute hypoxamic respiratory failure with mechanical ventilation set according to the ARDSNetwork trial aiming for tidal volumes less than 6ml/kg predicted body weight and plateau pressure less than or equal to 30cm H2O.
Previous interventions:
Intervention treatment will last for up to 7 days, patient follow up will be for 12 months.
INTERVENTION ARM: A dual lumen catheter will be inserted into a central vein and veno-venous extracorpoeal carbon dioxide removal (vv-ECCO2R) initiated as soon as possible and no later than 8 hours after randomisation. The pump blood flow rate and gas flow through the vv-ECCO2R device will be set up according to study manual. Thereafter tidal volumes on mechanical will be gradually decreased to less than or equal to 3ml/kg predicted body weight maintaining arterial pH of greater than 7.2 and plateau pressure less than or equal to 25cm H2O. A heparin infusion is used as anticoagulation to prevent circuit clotting. vv-ECCO2R will be considered for weaning after a minimum of 48 hours when weaning criteria are achieved.
CONTROL ARM: Standard management of acute hypoxamic respiratory failure with mechanical ventilation set according to the ARDSNetwork trial aiming for tidal volumes less than 6ml/kg predicted body weight and plateau pressure less than or equal to 30cm H2O.
Intervention type
Device
Phase
Drug names
Primary outcome measure
Mortality at 90 days after randomisation
Secondary outcome measures
Current secondary outcome measures as of 23/05/2017:
1. Tidal volume (ml/kg PBW) at day 1 and day 3 after randomisation (updated 05/03/2019: at day 2 and day 3 after randomisation)
2. Ventilator free days at 28 days after randomisation
3. Duration of ventilation in survivors after randomisation at 28 days
4. Need for ECMO up to Day 7
5. Mortality rate at 28 days, 6 months and 1 year after randomisation
6. Health Related Quality of Life (HRQoL) at 6 months and 1 year after randomisation
7. Adverse event rate
8. Health and Social Care Service costs at 6 months and 1 year
9. Saint George’s Respiratory Questionnaire (SGRQ) at 1 year and need for home oxygen at 6 months and 1 year after randomisation
10. Post Traumatic Stress Syndrome Questionnaire (PTSS-14) at 1 year after randomisation
11. Montreal Cognitive Assessment (MoCA-BLIND) or AD8 Dementia Screening Interview (AD8) at 1 year after randomisation
Previous secondary outcome measures:
1. Tidal volume (ml/kg PBW) at day 1 and day 3 after randomisation
2. Ventilator free days at 28 days after randomisation
3. Duration of ventilation in survivors after randomisation at 28 days
4. Need for ECMO up to Day 7
5. Mortality rate at 28 days, 6 months and 1 year after randomisation
6. Health Related Quality of Life (HRQoL) at 6 months and 1 year after randomisation
7. Adverse event rate
8. Health and Social Care Service costs at 6 months and 1 year
9. Saint George’s Respiratory Questionnaire (SGRQ) at 1 year and need for home oxygen at 6 months and 1 year after randomisation
Added 05/03/2019:
Exploratory outcomes:
Right heart function as determined by echocardiography during 6ml/kg PBW and ≤3ml/kg PBW tidal volume ventilation (ECHO data will only be collected at a selected number of sites)
Overall trial start date
01/03/2016
Overall trial end date
01/08/2021
Reason abandoned (if study stopped)
Eligibility
Participant inclusion criteria
1. Invasive mechanical ventilation using PEEP ≥ 5cmH2O*
2. Acute and potentially reversible cause of acute respiratory failure as determined by the treating physician
3. Within 48 hours of the onset of hypoxaemia as defined by PaO2/FiO2 ≤ 20kPa**
*Recommended on low tidal volume ventilation ≤ 6 ml/kg PBW
**Requires two ABG with a PaO2/FiO2 ≤ 20kPa separated by at least 6 hours. 48 hour duration begins at the time of 2nd ABG demonstrating PaO2/FiO2 ratio ≤ 20kPa. Added 05/03/2019: Site will then have a further 8 – 24 hours to randomise and administer the intervention. Added 23/05/2017: The onset of hypoxaemia is from time of intubation and invasive ventilation.
(ABGs with PaO2/FiO2 ≥ 20kPa are permitted between the two trial inclusion ABGs).
Participant type
Patient
Age group
Adult
Gender
Both
Target number of participants
1120
Participant exclusion criteria
Current exclusion criteria as of 23/05/2017:
1. Age <16 years old
2. Intubated and mechanically ventilated via an endotracheal or tracheostomy tube ≥ 7 days (168 hours) up to the time of randomisation
3. Ability to maintain Vt to ≤ 3ml/kg PBW while maintaining pH ≥ 7.2 as determined by the treating physician
4. Receiving, or decision to commence, ECMO in the next 24 hours.
5. Mechanical ventilation using HFOV or APRV
6. Untreated pulmonary embolism, pleural effusion or pneumothorax as the primary cause of acute respiratory failure.
7. Acute respiratory failure fully explained by left ventricular failure or fluid overload (May be determined by clinical assessment or echocardiography/cardiac output monitoring).
8. Left ventricular failure requiring mechanical support
9. Contra-indication to limited systemic anticoagulation with heparin
10. Unable to obtain vascular access to a central vein (internal jugular or femoral vein)
11. Inferior vena cava filter (if using femoral vein catheter)
12. Consent declined
13. Treatment withdrawal imminent within 24 hours
14. Patients not expected to survive 90 days on basis of premorbid health status
15. DNAR (Do Not Attempt Resuscitation) order in place (added 05/03/2019: excluding advance directives)
16. Severe chronic respiratory disease requiring domiciliary ventilation (except for sleep disordered breathing)
17. Severe chronic liver disease (Child Pugh >11)
18. Platelet count < 40,000 mm3 (added 05/03/2019: prior to catheter insertion)
19. Previously enrolled in the REST trial
20. Prisoners
Previous exclusion criteria:
1. Age <16 years old
2. Intubated and mechanically ventilated via an endotracheal or tracheostomy tube ≥ 7 days (168 hours) up to the time of randomisation
3. Ability to maintain Vt to ≤ 3ml/kg PBW while maintaining pH ≥ 7.2 as determined by the treating physician
4. Receiving, or decision to commence, ECMO in the next 24 hours.
5. Mechanical ventilation using HFOV or APRV
6. Untreated pulmonary embolism, pleural effusion or pneumothorax as the primary cause of acute respiratory failure.
7. Acute respiratory failure fully explained by left ventricular failure or fluid overload (May be determined by clinical assessment or echocardiography/cardiac output monitoring).
8. Left ventricular failure requiring mechanical support
9. Contra-indication to limited systemic anticoagulation with heparin
10. Unable to obtain vascular access to a central vein (internal jugular or femoral vein)
11. Inferior vena cava filter (if using femoral vein catheter)
12. Consent declined
13. Treatment withdrawal imminent within 24 hours
14. Patients not expected to survive 6 months on basis of premorbid health status
15. DNAR (Do Not Attempt Resuscitation) order in place
16. Severe chronic respiratory disease requiring domiciliary ventilation (except for sleep disordered breathing)
17. Severe chronic liver disease (Child Pugh >11)
18. Platelet count < 40,000 mm3
19. Previously enrolled in the REST trial
Recruitment start date
01/06/2016
Recruitment end date
11/02/2020
Locations
Countries of recruitment
United Kingdom
Trial participating centre
Royal Hospitals
Grosvenor Road
Belfast
BT12 6BA
United Kingdom
Trial participating centre
St Thomas' Hospital
London
SE1 7EH
United Kingdom
Trial participating centre
Kings College Hospital
London
SE5 9RS
United Kingdom
Trial participating centre
Manchester Royal Infirmary
Manchester
M13 9WL
United Kingdom
Trial participating centre
St James Hospital, Leeds
Great George Street
Leeds
LS1 3EX
United Kingdom
Trial participating centre
Hammersmith Hospital
London
W12 0HS
United Kingdom
Trial participating centre
Charing Cross Hospital
London
W6 8RF
United Kingdom
Trial participating centre
Royal Infirmary of Edinburgh
Edinburgh
EH16 4SB
United Kingdom
Trial participating centre
Birmingham Heartlands Hospital & Good Hope
Birmingham
B9 5SS
United Kingdom
Trial participating centre
Wythenshawe Hospital
Manchester
M23 9LT
United Kingdom
Trial participating centre
Queen Elizabeth Hospital
Mindelsohn Way
Birmingham
B15 2TH
United Kingdom
Trial participating centre
Royal Liverpool University Hospital
Liverpool
L7 8XP
United Kingdom
Trial participating centre
Royal Free Hospital
London
NW3 2QG
United Kingdom
Trial participating centre
University Hospital of Wales
Cardiff
CF14 4XW
United Kingdom
Trial participating centre
Addenbrookes Hospital
Cambridge
CB2 0QQ
United Kingdom
Trial participating centre
Royal Victoria Infirmary
Newcastle
NE1 4LP
United Kingdom
Trial participating centre
Papworth Hospital
Cambrideshire
CB23 3BE
United Kingdom
Trial participating centre
Royal Blackburn Hospital
Blackburn
BB2 3HH
United Kingdom
Trial participating centre
John Radcliffe Hospital
Oxford
OX3 9DU
United Kingdom
Trial participating centre
Royal Berkshire Hospital
Reading
RG1 5AN
United Kingdom
Trial participating centre
Sandwell General Hospital
West Bromwich
B71 4HJ
United Kingdom
Trial participating centre
Poole Hospital
Poole
BH15 2JB
United Kingdom
Trial participating centre
Royal Cornwall Hospital
Cornwall
TR1 3LJ
United Kingdom
Trial participating centre
Worcester Royal Hospital
Worcester
WR5 1DD
United Kingdom
Trial participating centre
New Cross Hospital
Wolverhampton
WV10 0QP
United Kingdom
Trial participating centre
St Georges Hospital
Tooting
SW17 0QT
United Kingdom
Trial participating centre
Altnagelvin Hospital
Derry
BT47 6SB
United Kingdom
Trial participating centre
Royal Stoke Hospitals
Stoke
ST4 6QG
United Kingdom
Trial participating centre
Royal Infirmary
Glasgow
G4 0SF
United Kingdom
Trial participating centre
Norfolk & Norwich University Hospital
Norwich
NR4 7UY
United Kingdom
Trial participating centre
Pinderfields Hospital
Wakefield
WF1 4DG
United Kingdom
Trial participating centre
Aintree University Hospital
Liverpool
L9 7AL
United Kingdom
Trial participating centre
Antrim Area Hospital
Antrim
BT41 2RL
United Kingdom
Trial participating centre
Royal London Hospital
London
E1 1BB
United Kingdom
Trial participating centre
Queen Elizabeth Hospital
Glasgow
G51 4TF
United Kingdom
Trial participating centre
Chelsea & Westminster Hospital
London
SW10 9NH
United Kingdom
Trial participating centre
Derriford Hospital
Derriford Rd
Plymouth
PL6 8DH
United Kingdom
Trial participating centre
Musgrove Park Hospital
Stockmans Ln
Belfast
BT9 7JB
United Kingdom
Trial participating centre
Northwick Park Hospital
Watford Rd
Harrow
HA1 3UJ
United Kingdom
Trial participating centre
Queen Alexandra Hospital
Portsmouth
PO6 3LY
United Kingdom
Trial participating centre
Royal Brompton Hospital
Sydney St
Chelsea
London
SW3 6NP
United Kingdom
Trial participating centre
Royal Gwent Hospital
Cardiff Rd
Newport
NP20 2UB
United Kingdom
Trial participating centre
Royal Oldham Hospital
Rochdale Rd
Oldham
OL1 2JH
United Kingdom
Trial participating centre
University College Hospital
235 Euston Rd
Fitzrovia
London
NW1 2BU
United Kingdom
Trial participating centre
York Teaching Hospital
Wigginton Rd
York
YO31 8HE
United Kingdom
Funders
Funder type
Not defined
Funder name
National Institute for Health Research
Alternative name(s)
NIHR
Funding Body Type
government organisation
Funding Body Subtype
National government
Location
United Kingdom
Results and Publications
Publication and dissemination plan
We plan to publish our trial protocol and statistical analysis plan to ensure transparency in our methodology. The study findings will be presented at national and international meetings with abstracts on-line. Presentation at these meetings will ensure that results and any implications quickly reach all of the UK intensive care community. This will be facilitated by our investigator group which includes individuals in executive positions in the UK Intensive Care Society. In accordance with the open access policies proposed by the NIHR we aim to publish the clinical findings of the trial as well as a paper describing the cost-effectiveness in the NHS setting in high quality peer-reviewed open access (via Pubmed) journals. This will secure a searchable compendium of these publications and make the results readily accessible to the public, health care professionals and scientists. A final report will also be published in the NIHR HTA journal.
We will actively promote the findings of the study to journal editors and critical care opinion leaders to ensure the findings are widely disseminated (e.g. through editorials and conference presentations) and are included in future guidelines.
IPD sharing statement:
The datasets generated during and/or analysed during the current study are/will be available upon request from rest@nictu.hscni.net or call 028 90635794 and ask for a member of the REST team
Intention to publish date
31/12/2021
Participant level data
Available on request
Basic results (scientific)
Publication list
Publication citations
Additional files
- ISRCTN31262122_PIS.pdf - participant information sheet, uploaded 15/04/2016