COMMENTARY

The Pros and Cons of Extracorporeal Membrane Oxygenation for ARDS

Aaron B. Holley, MD

Disclosures

January 16, 2018

Using Extracorporeal Membrane Oxygenation for ARDS

Critical Care Medicine just published a pro-con debate. One side argued for extracorporeal membrane oxygenation (ECMO) as first-line therapy for acute respiratory distress syndrome (ARDS); the other side argued against it.[1,2] I've spent the past 18 months working at a medical center that uses ECMO in the medical intensive care unit. We've spent more than a few academic conferences debating ECMO's proper role in patient management. Timing and patient selection are hardly straightforward. Needless to say, the pro-con debate caught my eye.

Viewpoint

Like most pro-con debates in medical journals, this one is far less exciting than the article titles imply. No one actually argues for ECMO as "first-line" therapy for ARDS in the conventional sense. Both sides' authors recommend trying proven approaches (prone-positioning,[3] neuromuscular blockade,[4] low-tidal volumes[5]) prior to using ECMO. The authors of the "pro" argument try to get aggressive by advocating ECMO as first-line therapy for ARDS in two specific scenarios: (1) for patients transferred from facilities poorly equipped to manage them; and (2) for patients deteriorating too rapidly for standard interventions to have time to work. The "con" authors remind us of all critical care interventions that seemed to improve physiologic measures but ultimately had no impact on outcomes. Their point is that just because ECMO makes your blood gas look awesome, it doesn't mean it's worth the risk.

No real controversy here. Considering ECMO when evidence-based methods have failed or are unavailable is reasonable and is recommended by guidelines.[6] Still, important questions remain: When exactly does ECMO become worth the risk? How do hospitals without ECMO experience know when it's indicated? Is patient selection simply a matter of waiting for conventional methods to fail? For anyone who's worked in an ECMO program, the answer to the last question is "no"—there's a lot more to it.

Both authors cite the limited evidence to support benefits from ECMO, drawing mainly from the CESAR trial.[7] In truth, we don't know the answers to any of these questions.

That doesn't mean that we shouldn't use ECMO. In fact, its use is on the rise,[8] and anecdotally I've seen it provide life-saving support at my facility. The authors of the "con" argument say that ECMO should always be done in the context of a research protocol.[1] The "pro" authors feel that ECMO should be managed by specialty centers that handle advanced respiratory diseases.[2] I think they both have a point.

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