Proning position trial#
Proning position series#

Therefore, it is impossible to accurately assess mortality differences reported in the CESAR trial, as in large measure these differences may have reflected failure to provide adequate lung protective ventilation. Numerous studies strongly suggest that mortality risk in ARDS increases when tidal volume exceeds 6 mL/kg and plateau pressure exceeds 30 cm H 2O or driving pressure exceeds 15 cm H 2O.

However, it’s telling that only 70% of the control group received treatment by low volume-low pressure ventilation “at any time” compared to 93% of those randomized to receive ECMO.

Thus, the degree to which lung protective ventilation was achieved remains unknown.

Proning position trial#

Moreover, in contrast to other multi-center, randomized, controlled trials of ARDS, the authors of the CESAR trial didn’t publish detailed mechanical ventilation data from the first three to seven study days. 2 In essence, ECMO at a single treatment center was compared to ill-defined, usual care practice at referral hospitals. 2 The CESAR trial did not use explicit, well-defined methods, particularly regarding mechanical ventilation in the control group. Unfortunately, neither study provided high-level evidence that would advocate using this extraordinarily invasive and costly therapy that carries greater risks than PP.

Proning position series#

The justification for ECMO in ARDS is based largely on the 2009 CESAR trial 1 and the ANZ-ECMO case series during the H1N1 influenza pandemic. Li et al were unable to ascertain from their inquiries why so few patients receiving ECMO after 2013 did not first receive a trial of PP. Interestingly, more patients received PP prior to publication of the landmark 2013 PROSEVA study, which showed that PP decreased 28-day and 90-day mortality than after: 124/220 vs. Only 208 of 672 patients received PP prior to ECMO. These studies represented only 28% of those meeting inclusion criteria because only correspondence with those study investigators could confirm whether a prone position (PP) trial preceded ECMO initiation. Overall, 15 studies were published after 2010. The authors of this retrospective investigation examined 17 studies involving 672 patients who received extracorporeal membrane oxygenation (ECMO) between 19 for severe acute respiratory distress syndrome (ARDS). Unproven and expensive before proven and cheap - Extracorporeal membrane oxygenation vs. SYNOPSIS: Despite credible evidence from a large, randomized, controlled trial and numerous meta-analyses demonstrating improved outcomes, prone position is seldom attempted prior to initiating extracorporeal membrane oxygenation to treat severe acute respiratory distress syndrome. Kallet reports he is a major stockholder of and a business advisory board member for the Asthma & Allergy Prevention Company and receives grant/research support from Nihon-Kohden.

Director of Quality Assurance, Respiratory Care Services, Department of Anesthesia, San Francisco General Hospital