CHEST Guidelines-COUNTERPOINT--Should-Patients-With-Advanced-Lung-D

COUNTERPOINT--Should-Patients-With-Advanced-Lung-D

Pdf Summary

The debate over the use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) centers on whether it should be offered to patients with end-stage lung disease (ESLD) who have yet to be evaluated for transplantation. The article argues against using ECMO for patients not pre-listed for transplant, highlighting several concerns.<br /><br />Firstly, the survival outcomes for patients on ECMO, especially in lower-volume centers, are poorer compared to those not needing ECMO. High-volume centers with extensive ECMO and transplant experience achieve better survival rates, making the procedure more viable in such settings.<br /><br />Secondly, there is a significant mismatch between the number of ECMO centers and transplant centers, which may lead to more patients being put on ECMO than can receive transplants, potentially resulting in a "bridge to nowhere." This situation can place both patients and families in emotional turmoil if the patient is not eventually eligible for transplant.<br /><br />Additionally, the emotional bonds that form between medical teams and patients on ECMO might cloud objective decision-making for transplant candidacy, potentially leading to biased outcomes.<br /><br />Moreover, ECMO is a resource-intensive therapy, and its inappropriate use could violate principles of equitable resource distribution. Given these factors, it's argued that ECMO should not be broadly applied to patients not listed for transplant. Instead, early referrals to transplant centers for timely evaluations are suggested to prevent the need for ECMO as a salvage intervention.<br /><br />However, Gannon and colleagues argue that volume alone isn't the sole determinant of success; expertise and standardized decision-making are crucial. They emphasize not shying away from ethical challenges, advocating for offering ECMO-driven hope through considered individual case evaluations without prematurely opting for palliative care.<br /><br />In summary, while ECMO as a pre-listing bridge is controversial, especially outside high-volume centers, careful consideration, and a structured approach in experienced centers could align therapy with patient needs.

Keywords

ECMO

lung transplantation

end-stage lung disease

survival outcomes

high-volume centers

transplant candidacy

resource distribution

ethical challenges

individual case evaluations

structured approach