In April of 2019, Scheunemann et al. published a discussion in JAMA regarding care in ICUs. The intention was to evaluate if providers and patient advocates were keeping the patient’s values and preferences in mind when making important treatment decisions. The study involved the evaluation of recorded conferences held between providers and the persons making decisions for the critically ill. The patients that were studied were not able to speak for themselves, had been diagnosed with ARDS, and had at least a 50% predicted mortality risk while in the hospital. These recorded conferences were analyzed by coders for what the patients had previously indicated about types of treatments they would want, what their values were regarding healthcare, and what they would possibly choose in the given situation. They found that most of these conferences did not contain enough information about the possible prognosis and patient outcome and did not integrate enough discussion about the patient’s values and preferences regarding their health care. The study suggests that families, patient proxies, and providers need to be better prepared in these conversations to ensure appropriate decisions are made regarding the care and treatments that are implemented (Scheunemann et al., 2019).
ECMO has been utilized and studied for many decades and has been indicated as a treatment option for ARDS, but there has been controversy about when this treatment is appropriate. This type of life support has been used in persons with respiratory failure requiring the use of mechanical ventilation despite significant complications. With improvements in technology, ECMO has been revaluated. ECMO involves the withdrawal of venous blood via a cannula in the right femoral vein that is slowly advanced towards the right atrium. A pump draws the deoxygenated blood into a device known as the oxygenator. Room air and oxygen are delivered into the fibers of the oxygenator where gas exchange will take place, producing oxygenated blood and removing the carbon dioxide. The oxygenated blood is returned to the right atrium via a cannula that is inserted into the right jugular vein (Brodie, Slutsky & Combes, 2019).
This type of treatment can be used to support the lungs or cardiac system and is known by multiple names, including ECMO. There have been many recorded complications, which include hemorrhage, infarcts, seizures, pneumothorax, cardiac arrhythmia, cardiac tamponade, infections, and more. There is a need for further research and advances in technology to improve the function while decreasing the potential complications. There is a need for continued use of this type of treatment in acute respiratory failure, and patients who need the support for the right side of the heart. Other technologies are being studied that may ultimately change the way people are treated, where they are treated, and potentially could change lives (Brodie et al., 2019).
Aoyama et al. (2019) focused on patients who were diagnosed with moderate to severe ARDS using lung-protective ventilation versus other therapeutic interventions and what the outcomes would be. They looked at prone positioning and ECMO, and how their use would impact the mortality rate. Nine different treatment options were evaluated using a 28-day mortality rate in 7,753 patients. In patients who had moderate ARDS, using a prone position reduced the 28-day mortality rate significantly compared to patients who only had lung-protective ventilation. Patients who were diagnosed with severe ARDS and started on ECMO also had a significantly lower mortality rate. This study supports the continued use of lung-protective ventilation, prone positioning, and the need to further explore the use of ECMO earlier in the treatment of ARDS (Aoyama et al., 2019).