Faculty Opinions recommendation of Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial.

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Abstract
Extracorporeal membrane oxygenation (ECMO) was originally applied to patients with severe acute respiratory failure in whom it was impossible to provide adequate oxygenation by mechanical ventilation (MV). Substituting alveolar gas exchange by ECMO or extracorporeal carbon dioxide removal would allow a marked reduction of tidal volume, respiratory rate, and fraction of inspired oxygen (FiO2), reducing the risk of ventilator-induced lung injury. This randomized controlled trial, referred to as the CESAR (Conventional ventilatory support versus Extracorporeal membrane oxygenation for Severe Adult Respiratory failure) trial, assessed the effectiveness of ECMO in 180 patients with severe ARDS. However, rather than directly assessing ECMO in refractory hypoxemia, investigators compared ECMO management at a referring center with MV management at tertiary centers. The 6-month survival rate was higher at the ECMO center than those patients managed with MV at participating centers (63% versus 47%, p=0.03). Major concerns with the reported results included (i) patients allocated to MV were treated with conventional MV or with high-frequency ventilation, (ii) 30% of patients in the control group were not ventilated with a lung-protective strategy, (iii) the ECMO center did not treat patients randomly assigned to the conventional management group, (iv) no data regarding ventilation at study entry and during the MV period were presented, and (v) many patients randomly assigned to ECMO never received ECMO. A multicenter trial for severe ARDS is ongoing comparing ECMO to a protocolized lung protective MV strategy {1}. This Recommendation is of an article referenced in an F1000 Faculty Review also written by Jesús Villar, Carlos Ferrando, and Robert M Kacmarek.

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