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Alan H. Morris, MD, FCCP; Eliotte Hirshberg, MD; Russell R. Miller, III, MD, MPH; Kimberly D. Statler, MD; R. Duncan Hite, MD, FCCP
Author and Funding Information

From the Intermountain Medical Center (Drs Morris, Hirshberg, and Miller); the Health Sciences Center, University of Utah (Drs Hirshberg and Statler); and the Wake Forest University School of Medicine (Dr Hite).

Correspondence to: Alan H. Morris, MD, FCCP, Pulmonary/Critical Care Division, Sorenson Heart-Lung Center-6th Fl, 5121 S Cottonwood St, Murray, UT 84157-7000; e-mail: alan.morris@imail.org


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Morris received grant monies from Agency for Health Care Policy and Research for the initial work. Dr Hite is a shareholder of Discover Laboratories and a member of the Data Safety and Monitoring Board, Cumberland Pharmaceuticals, 2006 to present. Drs Hirshberg, Miller, and Statler 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(4):965-966. doi:10.1378/chest.10-3314
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To the Editor:

We appreciate the comments to our articles1,2 articulated by Dr MacLaren. We believe that he raises three issues in his correspondence: (1) Extracorporeal membrane oxygenation (ECMO) must be correctly applied, (2) ECMO must be applied to the appropriate patient, and (3) we need to define when, how, and in whom we can optimally use the technique, not whether ECMO is effective. These issues are crucial ones that can only be defined when a detailed method (for selection of patients, conduct of extracorporeal support, management of important clinical cointerventions) is documented and validated. Short of this, clinicians cannot know when, how, and in whom to optimally apply ECMO.

The alternative is to accept at face value the claim of experts that their experience in “managing adult patients on ECMO for refractory respiratory failure,” or similar expressions, demonstrates, documents, and validates the efficacy of ECMO. Unfortunately, such beliefs, no matter how strongly and sincerely held, are frequently proven to be invalid when formally tested using appropriate, scientifically rigorous methods. Past treatments enthusiastically supported and widely disseminated but subsequently shown to be of no value—or even harmful—include avoidance of β-blockers in heart failure treatment, insulin for schizophrenia, vitamin K for myocardial infarction, hormone replacement therapy to prevent cardiovascular disease, flecainide for ventricular tachycardia, and immobilization of scaphoid bone fractures.3 Many other examples could be mentioned.

Dr MacLaren cites the good outcome of his four patients with 2009 influenza A(H1N1), whom he supported with ECMO. One must be careful, we believe, to separate proper decision making from patient outcome. Because of the probabilistic nature of the link between decisions and outcomes, it is clear that good decisions can be followed by bad outcomes, and bad decisions followed by good outcomes.

We agree with Dr MacLaren that ECMO is easier to apply now than in the past. The ease of application, however, does not replace the need to know when, how, and in whom we can optimally use the technique. Citing the need for a multidisciplinary and expert team does little to answer this need.

We agree with Dr MacLaren that there exist “practical difficulties of conducting” randomized clinical trials. We believe that it is even more difficult to draw compelling conclusions from uncontrolled clinical experience. We recognize that this depends on the signal-to-noise ratio. It is possible that a large observed change in clinical outcome (eg, the response of pneumococcal pneumonia to penicillin in the 1940s) could produce compelling data, but this has not been the case with ECMO in adults with respiratory failure. Finally, the following quote seems appropriate: “To safeguard against ineffective or harmful health care we need doctors who want to do the best they can for their patients, who are willing to continually question their own managements, and who have readily available sources of information about what does work.”3

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]
 
Morris AH, Hirshberg E, Miller RR, Statler KD, Hite RD. Rebuttal from Dr Morris et al. Chest. 2010;1384:783-784. [CrossRef]
 
Doust J, Del Mar C. Why do doctors use treatments that do not work? BMJ. 2004;3287438:474-475. [CrossRef] [PubMed]
 

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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]
 
Morris AH, Hirshberg E, Miller RR, Statler KD, Hite RD. Rebuttal from Dr Morris et al. Chest. 2010;1384:783-784. [CrossRef]
 
Doust J, Del Mar C. Why do doctors use treatments that do not work? BMJ. 2004;3287438:474-475. [CrossRef] [PubMed]
 
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