0
Correspondence |

Turning the Dial to Futility FREE TO VIEW

James E. Lynch, MD; Joseph B. Zwischenberger, MD, FCCP
Author and Funding Information

From the Department of Surgery, University of Kentucky College of Medicine.

Correspondence to: Joseph B. Zwischenberger, MD, FCCP, Department of Surgery, University of Kentucky College of Medicine, 800 Rose St, MN264, Lexington, KY 40536-0298; e-mail: j.zwische@uky.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Zwischenberger currently receives grant monies from Ikaria, MC3, and the National Institutes of Health; receives royalties from Avalon for his patent for a double lumen cannula; is a consultant to Novalung; and serves on an advisory board for Ikaria. Dr Lynch has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this letter.

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):230-231. doi:10.1378/chest.10-1994
Text Size: A A A
Published online

To the Editor:

In a recent editorial in CHEST (April 2010), Hubmayr and Farmer1 questioned the rationale of “rescuing” patients with 2009 influenza A(H1N1) by using extracorporeal membrane oxygenation (ECMO) when they are failing using conventional treatment. The argument was made that results2-6 similar to what has been reported in New Zealand7 with the use of ECMO can be achieved without ECMO or other critical-care interventions (eg, nitric oxide [NO], prone positioning). The authors argue that physiologic end points that have been deemed unsafe may need further study. We agree with the authors that several laboratory investigations call into question the currently considered limits of human physiologic end points. Indeed, we have explored some of the same limits in our large animal studies of ARDS, including CO2 removal, pH regulation, and partial respiratory support.8,9

Although we agree that specific entry criteria for ECMO remain a moving target, pushing the physiologic envelope to the point of harm is counterproductive. The lesson learned from the numerous low-tidal-volume and positive end-expiratory pressure trials may be that the ventilator dials can only be “tweaked” to the point of minimizing harm before the point of futility is reached. Patients who cannot be supported by the ventilator are the target ECMO audience. Until we can predict with certainty which patients are at risk for death or long-term morbidity from severe respiratory physiologic extremes, we support ECMO when the “turning of the dials” reaches the point of futility.

We cannot continue to judge the efficacy or risk of ECMO on the basis of 20-year-old (and 30-year-old) trial data. The high morbidity and mortality seen in those trials are no longer relevant to a discussion of critical care in 2010. The real lesson of the CESAR (Conventional Ventilation or ECMO for Severe Adult Respiratory Failure) trial is that patients cared for in a high-volume critical-care hospital with the latest critical-care techniques, including ECMO, NO, and prone positioning, do significantly better than patients in a community hospital.10 The CESAR trial showed that the high morbidity previously reported with cannulation for ECMO is also a thing of the past. Through improved technology, the risk/benefit comparison for ECMO has changed. The best evidence to date remains that outcomes at a hospital with a full armamentarium of critical-care interventions, including ECMO, are better than in a community hospital.

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]
 
Domínguez-Cherit G, Lapinsky SE, Macias AE, et al. Critically ill patients with 2009 influenza A(H1N1) in Mexico. JAMA. 2009;30217:1880-1887. [CrossRef] [PubMed]
 
Jain S, Kamimoto L, Bramley AM, et al; 2009 Pandemic Influenza A (H1N1) Virus Hospitalizations Investigation Team 2009 Pandemic Influenza A (H1N1) Virus Hospitalizations Investigation Team Hospitalized patients with 2009 H1N1 influenza in the United States, April-June 2009. N Engl J Med. 2009;36120:1935-1944. [CrossRef] [PubMed]
 
Kumar A, Zarychanski R, Pinto R, et al; Canadian Critical Care Trials Group H1N1 Collaborative Canadian Critical Care Trials Group H1N1 Collaborative Critically ill patients with 2009 influenza A(H1N1) infection in Canada. JAMA. 2009;30217:1872-1879. [CrossRef] [PubMed]
 
Louie JK, Acosta M, Winter K, et al; California Pandemic (H1N1) Working Group California Pandemic (H1N1) Working Group Factors associated with death or hospitalization due to pandemic 2009 influenza A(H1N1) infection in California. JAMA. 2009;30217:1896-1902. [CrossRef] [PubMed]
 
Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC) Intensive-care patients with severe novel influenza A (H1N1) virus infection—Michigan, June 2009. MMWR Morb Mortal Wkly Rep. 2009;5827:749-752. [PubMed]
 
Davies A, Jones D, Bailey M, et al; Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA. 2009;30217:1888-1895. [CrossRef] [PubMed]
 
Schmalstieg FC, Keeney SE, Rudloff HE, et al. Arteriovenous CO2 removal improves survival compared to high frequency percussive and low tidal volume ventilation in a smoke/burn sheep acute respiratory distress syndrome model. Ann Surg. 2007;2463:512-521. [CrossRef] [PubMed]
 
Vertrees RA, Nason R, Hold MD, et al. Smoke/burn injury-induced respiratory failure elicits apoptosis in ovine lungs and cultured lung cells, ameliorated with arteriovenous CO2 removal. Chest. 2004;1254:1472-1482. [CrossRef] [PubMed]
 
Peek GJU, 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]
 

Figures

Tables

References

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]
 
Domínguez-Cherit G, Lapinsky SE, Macias AE, et al. Critically ill patients with 2009 influenza A(H1N1) in Mexico. JAMA. 2009;30217:1880-1887. [CrossRef] [PubMed]
 
Jain S, Kamimoto L, Bramley AM, et al; 2009 Pandemic Influenza A (H1N1) Virus Hospitalizations Investigation Team 2009 Pandemic Influenza A (H1N1) Virus Hospitalizations Investigation Team Hospitalized patients with 2009 H1N1 influenza in the United States, April-June 2009. N Engl J Med. 2009;36120:1935-1944. [CrossRef] [PubMed]
 
Kumar A, Zarychanski R, Pinto R, et al; Canadian Critical Care Trials Group H1N1 Collaborative Canadian Critical Care Trials Group H1N1 Collaborative Critically ill patients with 2009 influenza A(H1N1) infection in Canada. JAMA. 2009;30217:1872-1879. [CrossRef] [PubMed]
 
Louie JK, Acosta M, Winter K, et al; California Pandemic (H1N1) Working Group California Pandemic (H1N1) Working Group Factors associated with death or hospitalization due to pandemic 2009 influenza A(H1N1) infection in California. JAMA. 2009;30217:1896-1902. [CrossRef] [PubMed]
 
Centers for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC) Intensive-care patients with severe novel influenza A (H1N1) virus infection—Michigan, June 2009. MMWR Morb Mortal Wkly Rep. 2009;5827:749-752. [PubMed]
 
Davies A, Jones D, Bailey M, et al; Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA. 2009;30217:1888-1895. [CrossRef] [PubMed]
 
Schmalstieg FC, Keeney SE, Rudloff HE, et al. Arteriovenous CO2 removal improves survival compared to high frequency percussive and low tidal volume ventilation in a smoke/burn sheep acute respiratory distress syndrome model. Ann Surg. 2007;2463:512-521. [CrossRef] [PubMed]
 
Vertrees RA, Nason R, Hold MD, et al. Smoke/burn injury-induced respiratory failure elicits apoptosis in ovine lungs and cultured lung cells, ameliorated with arteriovenous CO2 removal. Chest. 2004;1254:1472-1482. [CrossRef] [PubMed]
 
Peek GJU, 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]
 
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