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ECMO vs. Prone Position in ARDS: The Curious Rejection of Evidence-based Practice

Kallet, Richard

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Critical Care Alert

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Critical Care Alert

Atlanta: Relias Learning

Citation/Abstract coverage: Jan 2008 - present

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; Atlanta Vol. 26, Iss. 1,  (Apr 2018).

Mr. Kallet reports he is a major stockholder of and a business advisory board member for the Asthma & Allergy Prevention Company and receives grant/research support from Nihon-Kohden.

SOURCE : Li X, Scales DC, Kavanagh BP. Unproven and expensive before proven and cheap — Extracorporeal membrane oxygenation vs. prone position in ARDS. Am J Respir Crit Care Med 2018 Jan 9. doi: 10.1164/rccm.201711-2216CP. [Epub ahead of print].

The authors of this retrospective investigation examined 17 studies involving 672 patients who received extracorporeal membrane oxygenation (ECMO) between 1997 and 2017 for severe acute respiratory distress syndrome (ARDS). Overall, 15 studies were published after 2010. These studies represented only 28% of those meeting inclusion criteria because only correspondence with those study investigators could confirm whether a prone position (PP) trial preceded ECMO initiation. Only 208 of 672 patients received PP prior to ECMO. Interestingly, more patients received PP prior to publication of the landmark 2013 PROSEVA study, which showed that PP decreased 28-day and 90-day mortality than after: 124/220 vs. 84/452, respectively ( P < 0.05). Li et al were unable to ascertain from their inquiries why so few patients receiving ECMO after 2013 did not first receive a trial of PP.

COMMENTARY

The justification for ECMO in ARDS is based largely on the 2009 CESAR trial ¹ and the ANZ-ECMO case series during the H1N1 influenza pandemic. Unfortunately, neither study provided high-level evidence that would advocate using this extraordinarily invasive and costly therapy that carries greater risks than PP. ² The CESAR trial did not use explicit, well-defined methods, particularly regarding mechanical ventilation in the control group. ² In essence, ECMO at a single treatment center was compared to ill-defined, usual care practice at referral hospitals. Moreover, in contrast to other multi-center, randomized, controlled trials of ARDS, the authors of the CESAR...