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Korean J Crit Care Med > Volume 31(2); 2016 > Article
Lee: The Future of Research on Extracorporeal Membrane Oxygenation (ECMO)
Since extracorporeal membrane oxygenation (ECMO) was introduced as a treatment modality for respiratory failure in 1972 by Hill et al.,[1] it has provided support to patients with inadequate oxygen delivery for days to weeks. Clinicians have used ECMO to increase oxygen delivery in severe lung disease, ineffective cardiac output from circulatory failure, or combined cardiopulmonary failure. ECMO has typically been applied in rescue situations that were refractory to conventional therapy.[2] Recently, researchers in the U.S., Germany, and Taiwan reported a rapid increase in the use of ECMO in their countries.[3-5] Diseases such as the H1N1 pandemic influenza,[6] the development of ECMO technology,[7] and the publication of randomized clinical trials have likely contributed to an increase in the use of ECMO.[8]
In contrast to the growing worldwide use of ECMO, evidence of its use in critical care situations is still lacking.[9] In particular, there is not much evidence supporting ECMO use in adult patients with Acute Respiratory Distress Syndrome (ARDS) and there is a paucity of rigorous experiments on its use in these patients.[10] Only 4 randomized clinical trials on the use of extracorporeal life support in ARDS have been previously reported.[11-14] Most of the existing publications on ECMO use are observational studies of a retrospective review, clinical experiences, and clinical reports.
Last year, the Korean Journal of Critical Care Medicine (KJCCM) published 11 papers which described the use of ECMO. Most of them were clinical reports of various clinical situations related to ECMO use, and one publication was an original article of a retrospective review. Publications such as clinical or case reports may not provide direct evidence, however they can provide important information and influence clinicians to consider new or different treatments in certain clinical situations. This issue of KJCCM includes two new case reports on the use of ECMO. The first case report describes a transient complication of ECMO that was corrected in a neonate,[15] and the second is a case on ECMO use in aspiration pneumonia in a single lung.[16] Both cases are conceivable situations for clinicians similar to previous case reports published in this journal.
A key question is how to organize such case reports or series so that they provide findings that are close to evidence. To cite one example, ECMO complications can arise either from patient factors or ECMO circuit components. Due to the diversity in indications (e.g., patient factors) and ECMO techniques (e.g., ECMO circuit components), detailed and replicable methods for conducting ECMO have not been described. This diversity and absence of adequately explicit protocols both contribute to the development of variable complications that are difficult to categorize. Cheng et al.[17] conducted a meta-analysis on ECMO complications during treatment of cardiogenic shock or cardiac arrest in adult patients. They simplified the analysis by selecting only venoarterial type ECMO and only cardiogenic shock or cardiac arrest patients. They also only included studies that reported complication rates on 10 or more patients.
Enlarging sample size allows a retrospective cohort study publication to be classified as more of a systematic review. In particular, tertiary referral centers are able to collect and analyze data from many ECMO cases more easily.[18,19] Because each institution has their own standard circuit, a single center study has the advantage of consistent analysis. If studies are not conducted at a single center or do not have enough cases, data can be collected from several centers through networks, as in the study by Kanji et al.[20]
ECMO case reports are consistently submitted to KJCCM. Performing studies to collect, categorize, and analyze ECMO experiences is worth attempting for critical care physicians who are working at a critical care unit. This place of work is a very intimate factor in ECMO research, since many different departments are involved in the ECMO procedure, all of which specialize in intensive or critical care. Whether a department, an institute, or a society takes the lead, we look forward to the submission of more research beyond simple case reports on ECMO use in the future.

NOTES

No potential conflict of interest relevant to this article was reported.

References

1. Hill JD, O’Brien TG, Murray JJ, Dontigny L, Bramson ML, Osborn JJ, et al. Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med 1972;286:629-34.
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2. Makdisi G, Wang IW. Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology. J Thorac Dis 2015;7:E166-76.
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3. McCarthy FH, McDermott KM, Kini V, Gutsche JT, Wald JW, Xie D, et al. Trends in U.S. Extracorporeal membrane oxygenation use and outcomes: 2002-2012. Semin Thorac Cardiovasc Surg 2015;27:81-8.
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4. Karagiannidis C, Brodie D, Strassmann S, Stoelben E, Philipp A, Bein T, et al. Extracorporeal membrane oxygenation: evolving epidemiology and mortality. Intensive Care Med 2016;42:889-96.
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5. Hsu CP, Lee WC, Wei HM, Sung SH, Huang CY, Shih CC, et al. Extracorporeal membrane oxygenation use, expenditure, and outcomes in Taiwan from 2000 to 2010. J Epidemiol 2015;25:321-31.
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6. Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators; Davies A, Jones D, Bailey M, Beca J, Bellomo R, et al. Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. JAMA 2009;302:1888-95.
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7. Giani M, Zanella A, Sangalli F, Pesenti A. Newer Indications and challenges. In: ECMO-extracorporeal life support in adults. In: Sangalli F, , Patroniti N, , Pesenti A. Milano, Springer. 2014, pp 463-72.

8. Terragni P, Faggiano C, Ranieri VM. Extracorporeal membrane oxygenation in adult patients with acute respiratory distress syndrome. Curr Opin Crit Care 2014;20:86-91.
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9. Tramm R, Ilic D, Davies AR, Pellegrino VA, Romero L, Hodgson C. Extracorporeal membrane oxygenation for critically ill adults. Cochrane Database Syst Rev 2015;22(1):CD010381.
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10. Hirshberg E, Zampieri F, Lanspa M, Bennett KS, Hite RD, Morris AH. Is Extracorporeal Life Support an Evidence-Based Intervention for Critically Ill Adults with ARDS?. In: Evidence-Based Practice of Critical Care. 2nd Ed. In: Deutschman CS, , Neligan PJ. Philadelphia, Elsevier Inc. 2015, pp 66-74.

11. Zapol WM, Snider MT, Hill JD, Fallat RJ, Bartlett RH, Edmunds LH, et al. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA 1979;242:2193-6.
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12. Morris AH, Wallace CJ, Menlove RL, Clemmer TP, Orme JF Jr, Weaver LK, et al. Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med 1994;149(2 Pt 1):295-305.
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13. Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, et al. 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;374:1351-63.
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14. Bein T, Weber-Carstens S, Goldmann A, Müller T, Staudinger T, Brederlau J, et al. Lower tidal volume strategy (≈3 ml/kg) combined with extracorporeal CO2 removal versus ‘conventional’ protective ventilation (6 ml/kg) in severe ARDS: the prospective randomized Xtravent-study. Intensive Care Med 2013;39:847-56.
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15. Choi SJ, Park CS, Jhang WK, Park SJ. Extracorporeal membrane oxygenation cannula malposition in the azygos vein in a neonate with right-sided congenital diaphragmatic hernia. Korean J Crit Care Med 2016;31:152-5.
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16. Jo J, Ryu YG. Extracorporeal membrane oxygenation therapy for aspiration pneumonia in a patient following left pneumonectomy for lung cancer. Korean J Crit Care Med 2016;31:156-61.
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17. Cheng R, Hachamovitch R, Kittleson M, Patel J, Arabia F, Moriguchi J, et al. Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Ann Thorac Surg 2014;97:610-6.
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18. Kim HY, Na S, Paik HC, Ha J, Kim J. Perioperative risk factors associated with immediate postoperative extracorporeal membrane oxygenation in lung transplants. Korean J Crit Care Med 2015;30:286-94.
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19. Ma DS, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW. Outcomes of venovenous extracorporeal membrane oxygenation support for acute respiratory distress syndrome in adults. Korean J Thorac Cardiovasc Surg 2012;45:91-4.
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20. Kanji HD, McCallum J, Norena M, Wong H, Griesdale DE, Reynolds S, et al. Early veno-venous extracorporeal membrane oxygenation is associated with lower mortality in patients who have severe hypoxemic respiratory failure: a retrospective multicenter cohort study. J Crit Care 2016;33:169-73.
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