Résumé
Des avancées majeures ont été réalisées dans la dernière décennie dans la conception des circuits d’extracorporeal membrane oxygenation (ECMO), et les résultats positifs de l’essai CESAR ont relancé l’intérêt pour la technique chez les malades présentant les formes les plus sévères de syndrome de détresse respiratoire aiguë (SDRA). Ces dispositifs ont également été utilisés avec succès lors de la pandémie grippale A(H1N1). Cependant, l’essai CESAR comporte de nombreuses limites méthodologiques, et les résultats des cohortes rétrospectives sont biaisés par la sélection initiale des malades qui ont reçu une ECMO. Avant une diffusion plus large de l’ECMO veinoveineuse pour les formes les plus sévères de SDRA, il apparaît souhaitable d’attendre les résultats d’essais randomisés en cours, dans lesquels l’ECMO est initiée précocement, les malades transférés rapidement sous ECMO vers un centre référent et la ventilation mécanique réglée en accord strict avec les recommandations internationales dans le groupe témoin.
Abstract
Major technological improvements in extracorporeal membrane oxygenation (ECMO) machines and the positive results of the CESAR trial have reignited the interest for veno-venous (VV)-ECMO in patients with severe acute respiratory distress syndrome (ARDS) and persistent hypoxemia or hypercarbia on conventional mechanical ventilation. The technique has also been successfully used for the most severe ARDS cases associated with the recent Influenza A(H1N1) pandemic. However, since the CESAR study was criticized for methodological limitations and because results of non-randomized case-series of ECMO are prone to selection biases, indications for VV-ECMO use remain highly controversial. Before widespread diffusion of VV-ECMO for severe ARDS, new trials should test the efficacy of early initiation of the technique with tight control of mechanical ventilation in the control group, initiation of ECMO prior to transportation to ECMO centers, and the use of ECMO in every patient randomly assigned to receive it.
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Combes, A. Résultats de l’assistance respiratoire extracorporelle dans les syndromes de détresse respiratoire aiguë sévères. Réanimation 22 (Suppl 3), 633–642 (2013). https://doi.org/10.1007/s13546-014-0874-4
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DOI: https://doi.org/10.1007/s13546-014-0874-4