0
Correspondence |

Response FREE TO VIEW

Rolf D. Hubmayr, MD, FCCP; J. Christopher Farmer, MD, FCCP
Author and Funding Information

From the Department of Medicine (Dr Hubmayr) and the Department of Internal Medicine (Dr Farmer), Mayo Clinic.

Correspondence to: Rolf D. Hubmayr, MD, FCCP, Department of Medicine, Room 8-62, Stabile Bldg, Mayo Clinic, 200 First St SW, Rochester, MN 55905-0001.


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(1):231-232. doi:10.1378/chest.10-2165
Text Size: A A A
Published online

To the Editor:

We thank Drs Lynch and Zwischenberger for their thoughtful comments regarding the appropriate use of extracorporeal membrane oxygenation (ECMO) in patients with severe, refractory respiratory failure. Drs Lynch and Zwischenberger point out that the real lesson of the CESAR (Conventional Ventilation or ECMO for Severe Adult Respiratory Failure) trial is that patients who are referred to large centers with state-of-the-art critical care facilities do better than those patients cared for in community hospitals.1 We could not agree more! We simply caution that expertise in the delivery of critical-care services should not be confused with the availability of ECMO.

We concur with Drs Lynch and Zwischenberger that continued “turning of the [ventilator] dials,” in spite of a failure to achieve acceptable cardiopulmonary therapeutic end points, can lead to undesired outcomes. But for some patients, further efforts using conventional approaches, with different hands on the dials, can still yield benefit. In the CESAR trial, 22 of the 90 patients who were randomized to the ECMO center actually improved and recovered without ECMO.

Drs Lynch and Zwischenberger also point out that advances in the ease and safety of gaining vascular access have substantially reduced the risk to benefit ratio of ECMO. Once again we agree, only to point out that even in the hands of the CESAR investigators, the risk of serious vascular complications, including hemorrhagic stroke, remains between 3% and 5%. As we previously stated, we believe that this modality remains an experimental rescue therapy to be employed by “ECMO experts,” as opposed to a treatment that should be made generally available to all patients with severe ARDS.2

Considering the spectacular advances of Western medicine’s ability to support failing cardiopulmonary systems, there is no doubt in our minds that in certain centers the use of ECMO in treating patients with severe ARDS has become more than feasible. There is also little doubt that technologic and human capabilities will continue to improve and that improvements in patients’ outcomes will follow. The point of our editorial was not to argue against research and innovation, quite to the contrary. Our view is simply that the lessons of the worldwide 2009 influenza A(H1N1) epidemic do not support a costly, nationwide investment in new ECMO programs. We believe that the physiologic boundaries that define current treatment space do warrant more careful examination and that ECMO has a place as a research tool in that endeavor.

Peek GJ, Mugford M, Tiruvoipati R, et al; CESAR Trial Collaboration CESAR Trial Collaboration 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;3749698:1351-1363. [CrossRef] [PubMed]
 
Hubmayr RD, Farmer JC. Should we “rescue” patients with 2009 influenza A(H1N1) and lung injury from conventional mechanical ventilation? Chest. 2010;1374:745-747. [CrossRef] [PubMed]
 

Figures

Tables

References

Peek GJ, Mugford M, Tiruvoipati R, et al; CESAR Trial Collaboration CESAR Trial Collaboration 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;3749698:1351-1363. [CrossRef] [PubMed]
 
Hubmayr RD, Farmer JC. Should we “rescue” patients with 2009 influenza A(H1N1) and lung injury from conventional mechanical ventilation? Chest. 2010;1374:745-747. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543