Extracorporeal membrane oxygenation (ECMO) in severe adult respiratory distress syndrome

Abstract

Article assessedPeek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009; 374: 1351-63. Critical care issueSevere adult respiratory distress syndrome (ARDS) remains associated with high mortality despite improved ventilatory techniques. While extracorporeal membrane oxygenation (ECMO) is not uncommon in neonatal/pediatric critical care, studies had yet to show similar benefits in adults. Therefore, the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) Trial by Peek et al. 1 was eagerly anticipated. It was the first randomized study of ECMO in adult patients in over 15 yr and the largest ever concerning this condition. 2 Summary and key findingsIn this multicentre randomized control trial from the United Kingdom, 180 patients, aged 18-65 yr, were analyzed. The patients had severe but potentially reversible respiratory failure, a Murray Score of C 3.0 (determined by combining PaO 2 /F I 0 2 ratio, positive end expiratory pressure level, lung compliance, chest radiograph appearance, and F I 0 2 of 1.0), or uncompensated hypercapnea (pH \ 7.2) despite conventional treatment. They were randomized 1:1 to conventional management without transfer vs transfer to one site and consideration of ECMO. A greater proportion of patients randomized to consideration of ECMO were alive at six months compared with patients randomized to conventional management (63% or 57/90 vs 50% or 45/90, respectively). This outcome did not reach statistical significance (relative risk 0.73; 95% confidence interval [CI] [0.52-1.03]; P = 0.07). However, a significantly greater percentage of patients randomized to consideration of ECMO survived to six months without severe disability compared with patients randomized to conventional management (63% [57/90] vs 47% [41/87], respectively; relative risk 0.69; 95% CI [0.05-0.97]; P = 0.03). Referral for ECMO consideration was associated with 0.03 quality-adjusted years (QALYS) at six months. The cost per QALY for ECMO was 19,252 pounds sterling (GBP) (95% CI [7,200]). Despite conventional management, the authors concluded that it was appropriate to transfer adults with severe ARDS to a centre with an ECMO-based management protocol. Critical appraisalCurrent state of the literature and study relevance Extra corporeal membrane oxygenation is accepted as a standard-of-care for neonates and children with progressive respiratory and/or cardiac failure refractory to conventional management. [1][2][3] In contrast, adult ECMO is currently confined to a few specialized centres and reserved for exceptional cases. This is because of increased cost and logistics but also because of disappointing results from the two previous randomized trials. 4,5

Clinical review: Extracorporeal membrane oxygenation

“…Many physicians, however, were not fully convinced by the investigators' approach [45-47]. In fact, this pragmatic study really tested the differences in outcome between a specialized center with high-volume activity and single centers with low-volume activity.…”

Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies

“…The CESAR Trial and corresponding analysis compared conventional practice and ECMO treatment in only one institution [63,64]. Ninety ARDS patients were randomized to receive “best practice” conventional treatment, and 90 were randomized to receive VV-ECMO.…”

Year in Review 2015: Extracorporeal Membrane Oxygenation

“…Importantly, the successful use of ECMO in infants established ECMO as a technical success, which led to its expansion in other critical care populations. [6][7][8] The rise of ECMO has led to an increase in the number of publications related to patient care and practice. A description of some of the literature from the recent past is shared below.…”