What is your opinion about the use of extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS)? Do we have good-quality evidence to support its regular use?
Brian Garibaldi, MD: I think the evidence on the effectiveness of ECMO as either a definitive treatment strategy in ARDS or perhaps as salvage therapy is mixed. I think the evidence is best in centers that have a high volume of ECMO. We know that if you transfer patients to ECMO centers, where they have a lot of experience in both getting patients successfully on ECMO and managing the potential complications, it can be a reasonable salvage therapy for ARDS. In some centers it is used as the primary mode of therapy for ARDS.
Where the issue comes in is that there has not really been a high-quality trial looking at centers that are really experienced in using low tidal volume ventilation and managing a high volume of ARDS patients, randomizing patients at those centers to a standard of care that should be a low tidal volume ventilation arm [and] to ECMO. I think the answer to the question of which one would be most helpful is less clear in experienced centers.
But I think it is very clear that if you are going to use ECMO, you should transfer the patient to a center that has a lot of experience in ECMO because experience, in that case, really does matter.