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Correspondence |

Evidence and Experience in Extracorporeal Membrane Oxygenation FREE TO VIEW

Graeme MacLaren, MBBS, FCCP
Author and Funding Information

From the National University Health System and Royal Children’s Hospital (Melbourne, VIC, Australia).

Correspondence to: Graeme MacLaren, MBBS, FCCP, Cardiothoracic ICU, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074; gmaclaren@iinet.net.au


Financial/nonfinancial disclosures: The author has 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(4):965. doi:10.1378/chest.10-2729
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To the Editor:

I am in complete agreement with the comments of Morris et al1 recently published in CHEST (October 2010) that studies unequivocally demonstrating the benefits of extracorporeal membrane oxygenation (ECMO) in adult respiratory failure are lacking. One randomized trial using obsolete equipment and outdated intensive care practices is largely irrelevant to physicians practicing today.2 A more recent study showing some advantage to ECMO for this indication had some methodologic peculiarities, which left it susceptible to armchair criticism from potential detractors.3

However, I respectfully disagree with the arguments adopted by Morris et al1 to discount ECMO as rescue therapy, which, although of considerable epistemologic interest, are less helpful to the practicing physician. These arguments predominantly revolve around the nature of certainty and scientific proof. What proof should physicians deem sufficient in order to accept ECMO as rescue therapy? To me, the efficacy of ECMO when correctly applied to an appropriate patient is self-evident. To those who do not accept this position, the issue of conducting efficacy trials is problematic. Although ECMO is now easier to use than ever before, it is still a complex means of life support that requires the expertise of an experienced multidisciplinary team to apply with any finesse. Acquiring the skills needed to become expert in ECMO may rob physicians of the equipoise necessary to participate in a trial in which patients dying of hypoxic respiratory failure are randomized to rescue therapy with ECMO or yet more conventional treatment.

Randomized controlled trials have been regarded as the best way of answering scientific queries in clinical medicine, but the practical difficulties of conducting them often leave their results open to widely varying interpretation. It may be time to look at alternative forms of evidence in critically ill patients.4 Sir Karl Popper wrote, “If you insist on strict proof (or strict disproof) in the empirical sciences, you will never benefit from experience, and never learn from it how wrong you are.”5 My own experience in managing adult patients receiving ECMO for refractory respiratory failure caused by proven 2009 influenza A(H1N1) is limited. I have only attended to four such patients, two of whom also had concurrent circulatory collapse. Happily, all four patients completely recovered. Surely, it is time to move beyond the erroneous supposition that ECMO does little but harm. Stop calling for more efficacy trials and focus instead on when, how, and in whom we can optimally use the technique.

Morris AH, Hirshberg E, Miller RR III, Statler KD, Hite RD. Counterpoint: efficacy of extracorporeal membrane oxygenation in 2009 influenza A(H1N1): sufficient evidence? Chest. 2010;1384:778-781. [CrossRef] [PubMed]
 
Zapol WM, Snider MT, Hill JD, et al. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA. 1979;24220:2193-2196. [CrossRef] [PubMed]
 
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]
 
Vincent JL. We should abandon randomized controlled trials in the intensive care unit. Crit Care Med. 2010;3810:S534-S538. [CrossRef] [PubMed]
 
Popper KR. The Logic of Scientific Discovery. 2002; London, England Routledge Classics:28
 

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References

Morris AH, Hirshberg E, Miller RR III, Statler KD, Hite RD. Counterpoint: efficacy of extracorporeal membrane oxygenation in 2009 influenza A(H1N1): sufficient evidence? Chest. 2010;1384:778-781. [CrossRef] [PubMed]
 
Zapol WM, Snider MT, Hill JD, et al. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA. 1979;24220:2193-2196. [CrossRef] [PubMed]
 
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]
 
Vincent JL. We should abandon randomized controlled trials in the intensive care unit. Crit Care Med. 2010;3810:S534-S538. [CrossRef] [PubMed]
 
Popper KR. The Logic of Scientific Discovery. 2002; London, England Routledge Classics:28
 
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