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Intensive Care Med. 2017 Dec;43(12):1862-1865. doi: 10.1007/s00134-017-4933-7. Epub 2017 Sep 15.

Do we need randomized clinical trials in extracorporeal respiratory support? Yes.

Author information

1
Medical-Surgical Intensive Care Unit, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 75013, Paris, France. alain.combes@aphp.fr.
2
Sorbonne University Paris, INSERM, Institute of Cardiometabolism and Nutrition UMRS_1166-ICAN, 75013, Paris, France. alain.combes@aphp.fr.
3
Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, AND Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.
4
Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center/New York-Presbyterian Hospital, Columbia University, New York, NY, USA.

Abstract

Extracorporeal respiratory support, also known as extracorporeal gas exchange, may be used to rescue the most severe forms of acute hypoxemic respiratory failure with high blood flow venovenous extracorporeal membrane oxygenation. Alternatively, lower flow extracorporeal carbon dioxide removal might be applied to reduce the intensity of mechanical ventilation in patients with less severe forms of the disease. However, critical reading of the results of the randomized trials and case series published to date reveals major methodological biases. Older trials are not relevant anymore since the ECMO circuitry was not heparin-coated leading to severe hemorrhagic complications due to high levels of anticoagulation, and because extracorporeal membrane oxygenation (ECMO) and control group patients did not receive lung-protective ventilation. Alternatively, in the more recent CESAR trial, many patients randomized to the ECMO arm did not receive ECMO and no standardized protocol for lung-protective mechanical ventilation existed in the control group. Since these techniques are costly and associated with potentially serious adverse events, there is an urgent need for high-quality data, for which the cornerstone remains randomized controlled trials.

KEYWORDS:

Acute respiratory distress syndrome; Editorial; Extracorporeal CO2 removal; Extracorporeal membrane oxygenation; Mechanical ventilation

PMID:
28914339
DOI:
10.1007/s00134-017-4933-7
[Indexed for MEDLINE]

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