eolia, defining the role of ecmo for ards: an update combes.pdf · eolia, defining the role of ecmo...
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EOLIA, Defining The Role Of ECMO For ARDS: An Update …
Alain Combes
Service de Réanimation
iCAN, Institute of Cardiometabolism and Nutrition
Hôpital Pitié-Salpêtrière, AP-HP, Paris
Université Pierre et Marie Curie, Paris 6www.reamedpitie.com
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26° Congresso Nazionale della Società Italiana di Terapia Intensiva
Name…COMBES………………Surname…Alain…………..
I declare that in the last two years I had funding relationship with the followingsubjects with commercial interest:
Names of the Companies
___MAQUET, co-sponsor of the EOLIA trial, NCT01470703_______
___ GAMBRO, co-sponsor of the HEROICS trial, NCT01077349
_____
I also declare that these relationships are not such as to influence the teachingactivities of the present congress.
So I’m not in a situation of conflict of interest.
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Conflict of interest
Principal Investigator: HEROICS trial HVHF after complicated heart surgery NCT01077349 Sponsored by GAMBRO
Principal Investigator: EOLIA trial VV ECMO in ARDS NCT01470703 Sponsored by MAQUET, Getinge Group
Received honoraria from MAQUET, Getinge Group
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Do we really need more trials of ECMO for ARDS????
Analyzing evidence-based medicine data…
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YES, because ARDS is still a severe disease
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Hospital mortality: 58%
PaO2/FiO2 < 100 Subgroup
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YES, because VV-ECMO can result in good prognosis for severe ARDS
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Study population
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YES, because data fromretrospective series…
Will never eliminate the bias of patients’ selection to receive ECMO
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Et al…
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Et al…
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The French REVA Registry collected data of patients hospitalized in ICUs for H1N1-associated ARDS
Analysis of factors associated with death among 123 patients who received ECMO
Case-control study with matching on a propensity score to receive ECMO
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YES, because only 3 randomized trials…
And only one with 21st
century standard of care
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Zapol, W
Nine medical centers, Mid 70’s
Prospective randomized trial to evaluate ECMO for ARDS
90 adult patients selected
Mechanical ventilation + venoarterial ECMO (42 patients)
Conventional mechanical ventilation (48 patients)
Four patients in each group survived
Patients died of:
Progressive reduction of transpulmonary gas exchange
Decreased compliance due to diffuse pulmonary inflammation, necrosis, and fibrosis
“ECMO can support respiratory gas exchange but did not increase the probability of survival for severe ARDS”
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Zapol, W
Caveats of this first study
“Outdated” devices
Veino-arterial bypass only
ECMO weaned systematically at D5
Prolonged MV before randomization
“Old-fashioned” MV
Profound anticoagulation
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NEJM, 1972
BramsonECMO
machine
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NEJM, 1972
Did he survive despiteECMO????
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The “CESAR” trial…
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Time from randomization to death
Log rank p = 0.03
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“Dissecting” CESAR…
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14/17 (82%) survived with conventional ICU management alone after transfer to Leicester
Benefit reported not for ECMO alone But for a strategy of referral to a
single ECMO-capable hospital
For ECMO assessment and management if criteria are met
Did improved care at the single ECMO hospital lead to the relative risk observed???
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About †, ‡ and …
† Based on 177 patients with known primary outcome‡ % calculated with denominator of 87 patients
§ 3 patients discharged alive, alive at 6 months, but no information on disability
If the 3 patients in the control group had all been severely disabled, RR of the 1st outcome would be 0.72 (0.51–1.01, p=0.051)
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Should we transport severe ARDS patients without ECMO?
6% died without ECMO
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YES, we need a new trial to convince the skeptics…
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Hubmayr, Rolf D., [email protected]
Who really knows how the absolute risk of a plateau
pressure >30 “stacks up” against the risk associated with an ECMO run?
Who is to say that an Fio2 of 1.0 cannot be tolerated for some duration
without long-term consequence? There are those who believe
hypercapnic acidosis is lung protective…
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CohortANZ
Anzic groupNEJM, 09
Canada, Kumar
JAMA, 2009
Utah, The USAMiller
Chest 2010
Confirmed H1N1, n 722 162 47
Received MV, % 63% 84% 79%
Received ECMO, % 12% 4% 0
Mortality, % 15% 17% 17%
Critically ill patients during the 2009 H1N1 Influenza pandemic
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Hubmayr, Rolf D., [email protected]
At this time, we do not support the position that as a nation we should invest in
the development of additional ECMO centers
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Hubmayr, Rolf D., [email protected]
At this time, we do not support the position that as a nation we should invest in
the development of additional ECMO centers
Situation of EQUIPOISE
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PaO2 = 25 mm Hg
SaO2 = 55%
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Designing a new trial…
EOLIA: ECMO to rescue Lung Injury in severe ARDS
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EOLIA: ECMO to rescue Lung Injury in severe ARDS
Multicenter international randomized controlled trial
Best care possible in the ECMO arm
ECMO initiated asap for every patient randomized
• Using the most recent ECMO technology
Transport of randomized patients to the referral center UNDER ECMO
ECMO managed only in highly experienced centers
“Highly protective” MV
• Plateau pressure limited to ≤ 24 cm H2O
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EOLIA: ECMO to rescue Lung Injury in severe ARDS
Best care possible in the control arm
MV protocolized using the “high PEEP – high recruitment” strategy of the EXPRESS trial
To limit plateau pressure <28-30 cm H2O• Vt limited to 6 ml/kg IBW
Including Prone positioning
“Ethical” cross-over option to ECMO if the patient develops refractory hypoxemia
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EOLIA: ECMO to rescue Lung Injury in severe ARDS
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EOLIA: ECMO to rescue Lung Injury in severe ARDS
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We need EOLIA… A new trial of ECMO for severe pneumonia/ARDS
105 patients randomized so far…
YESWECAN
YESWECAN
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Conclusion
VV-ECMO can rescue 50-80% of the patients
with severe respiratory failure
50-70% of whom have severe pneumonia
Controversy still highly active regarding its
Real impact on the outcomes of patients with the
most severe forms of ARDS
EQUIPOISE for a new trial… the EOLIA trial!...
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May 21-24 2014