Chief Editor’s note: We are starting a new rubric, “Ground-breaking research”, with the aim to publish some important new research data applicable to clinical daily activity.
Our readers are kindly invited to contribute to this new initiative.
Summer and its longer and brighter days are an excellent moment to take a break, catch up with friends and family, and plan new projects and ideas for the year ahead. So we thought it would be of some usefulness for the Anaesthesiologist community to add a new section in the ESA newsletter of a review of a recently published landmark article. In each issue, the articles will refer to different fields of our speciality. Kicking off with Intensive Care Medicine, we are looking forward to receiving your comments or suggestions for future article discussions.
The acute respiratory distress syndrome (ARDS) remains a frequent condition; as many as 10% will suffer from it in Intensive Care Units,1with a non-depreciable mortality of 40%.1Extracorporeal membrane oxygenation has been part of treatment is cases of high severity, especially since 2009 with the H1N1 influenza pandemic. Although there is growth in their use, evidence from Randomised Controlled Trials is limited, the only exception is the CESAR Trial 2. Methodological issues restricted promising conclusions that could be drawn. Combes et al.3with EOLIA, an international RCT, aim to provide the final answer to best treatment for severe ARDS.
Conventional treatment, which included lung protective measures, prone positioning, lung recruitment manoeuvres, neuromuscular blocking agents, and pulmonary vasodilators (no inhaled prostacyclin), was compared with ECMO in patients in whom ARDS was diagnosed within 7 days. After randomisation to either group, the conventional treatment group had the possibility of crossing over to ECMO in cases of refractory hypoxaemia. The authors projected to enrol a maximum of 331 patients, but the trial was stopped earlier due to lack of significance between groups in primary endpoint (60-day mortality). A total of 124 patients were recruited in the ECMO group and 125 in the control group, 35 of whom received rescue ECMO. At 60 days, 44 died in the ECMO group (35%), 57 (46%) in the control group, and 20 (57%) in the control group that crossed over to ECMO at the discretion of the clinician with no pre-set criteria.
ECMO offers no mortality benefit to conventional mechanical ventilation for patients with severe ARDS. Despite the negative nature of trial, the results can be impacted by the number of patients in the control group (28%) who received ECMO. However, the degree of impact of these will never be known.
In light of these results, ECMO should continue to be in hospital policies for ARDS management but only after conventional management has been deployed and no satisfactory result obtained with ongoing refractory hypoxaemia.