[MEDSCAPE评论]:ECMO治疗ARDS的正反方辩论 | 中国病理生理学会危重病医学专业委员会
现在的位置: 首页研究点评, 进展交流>正文
[MEDSCAPE评论]:ECMO治疗ARDS的正反方辩论
2018年02月13日 研究点评, 进展交流 暂无评论

COMMENTARY

The Pros and Cons of Extracorporeal Membrane Oxygenation for ARDS

Aaron B. Holley, MD

January 16, 2018

Using Extracorporeal Membrane Oxygenation for ARDS

采用ECMO治疗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.

Critical Care Medicine刚刚发表了一个正反方辩论。一方认为ECMO是ARDS的一线治疗措施;另一方则反对这一观点。在过去18个月中,我所工作的内科ICU采用了ECMO技术,我们也花了很多时间讨论ECMO在患者治疗中的地位。ECMO的应用时机及患者选择尚不明确。毋须讳言,这个正反方辩论吸引了我。

Viewpoint 观点

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.

如同医学杂志中大多数正反方辩论一样,实际上这个辩论远远不如文章标题所提示的那样精彩。没人真正主张ECMO应该成为传统意义上的ARDS“一线治疗”。正反双方都建议在使用ECMO之前尝试已被证实的措施(俯卧位通气,肌松药物,小潮气量)。正方观点更为激进,建议在两种情况下ECMO应当成为ARDS的一线治疗措施:(1)从缺乏必要治疗设备的医院转诊来的患者;(2)病情迅速恶化导致标准治疗已经没有时间发挥作用的患者。反方提醒我们,所有的重症治疗措施看似能够改善生理指标,但是最终对临床结局并无影响。其观点为,不能因为ECMO使得患者血气分析结果更佳,就认为患者获益超过风险。

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.

在这里其实没有真正的矛盾之处。当循证治疗措施失败或无法实施时,考虑ECMO治疗是合理的,指南也是如此推荐的。然而,仍然存在重要的问题:何时才是进行ECMO治疗的适宜时机?没有ECMO经验的医院如何了解ECMO治疗的适应症?是否应当在等到传统治疗措施失败后再选择ECMO的患者?对于任何一位有ECMO经验的人而言,对最后一个问题的答案都是否定的—还有更多可以做的事情。

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.

正反双方都引用了有限的证据支持ECMO的益处,后者主要来自CESAR试验。事实上,我们并不知道上述任何问题的答案。

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.

但是,这并非意味着我们不应使用ECMO。事实上,ECMO的使用日益增多,我在医院中也看到过ECMO挽救患者生命的范例。反方认为,目前仅应当在研究中依据方案进行ECMO。而正方则感觉,应当在具有丰富经验处理复杂呼吸疾病的专科中心进行ECMO。我认为双方都有道理。

References

1. Stephens R, Brower RG. Extracorporeal membrane oxygenation is not first-line therapy for the acute respiratory distress syndrome. Crit Care Med. 2017;45:2074-2077.

2. Abrams D, Brodie D. Extracorporeal membrane oxygenation is first-line therapy for acute respiratory distress syndrome. Crit Care Med. 2017;45:2070-2073.

3. Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368:2159-2168.

4. Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363:1107-1116.

5. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:1301-1308.

6. Fan E, Del Sorbo L, Goligher EC, et al. An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: Mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 2017;195:1253-1263.

7. Peek G, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory port versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): A multicentre randomised controlled trial. Lancet. 2009;374:1351-1363.

8. Thiagarajan, Ravi R.; Barbaro, Ryan P, et al. ELSO Registry. Extracorporeal Life Support Organization Registry International Report 2016. ASIAO J. 2017;63:60-67.

给我留言

您必须 [ 登录 ] 才能发表留言!

×
腾讯微博