Comment 662 www.thelancet.com/respiratory Vol 6 September 2018 might ultimately help to identify the true significance of ECMO in ARDS. In the EOLIA trial’s outcome data, the 60-day survival does not match the numbers used in the sample size calculation for planning the study. Because of the consistently excellent conservative ARDS treatment in the control group, estimates for mortality were off by 14%. Even the ECMO group had a 60-day mortality that was 5 percentage points lower than expected. Therefore, the EOLIA trial should be seen as an exploratory study, rather than a final conclusion on the subject. In fact, using the actual results for 60-day mortality (35% ECMO vs 46% control, α=0·05, power 80%) reveals a modest estimated total sample size of 622 patients (311 per group). Although this number appears to be fairly low compared with other past randomised controlled trials in the field of lung-protective ventilation, it will regardless be challenging to convince sponsors and clinicians to support yet another randomised controlled trial. We propose a two-step approach that should be taken going forward: (1) a follow-up to elucidate the long- term (one-year) survival and cost-adjusted quality of life of the EOLIA trial patients; and (2) a new prospective, randomised, multicentre, international trial with an adjusted sample size of at least 622 patients to account for the expected actual effect size. Results from the follow-up study will be useful to discern the long-term effects of ECMO treatment and will be necessary to solicit substantial funding and support of caregivers for the ambitious undertaking of a new trial. Subsequently, the new large, multicentre, international trial should then serve two purposes: ultimately identifying the short-term (60-day) effect of ECMO treatment in general, and identifying patient populations that might be particularly eligible for ECMO therapy. We hope that such a study will finally prove the survival benefit of ECMO. With the encouraging aspects of the EOLIA trial in mind, we can already see a light at the end of the tunnel. Matthias Derwall, *Rolf Rossaint Department of Anaesthesiology, University Hospital Aachen, Medical Faculty, RWTH Aachen University, D-52074 Aachen, Germany rrossaint@ukaachen.de MD declares no competing interests. RR chairs the German Research Foundation’s (Deutsche Forschungsgemeinschaft) priority programme “Towards an Implantable Lung” (SPP 2014). The programme is scheduled to run for six years (2017–2023) and aims to work out limitations currently preventing long-term use and implantation of lung assist systems. RR and employees from his department have received funding within this programme (DFG SPP 2014: RO 2000/26–1). 1 Hill JD, O’Brien TG, Murray JJ, et al. Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med 1972; 286: 629–34. 2 Combes A, Pesenti A, Ranieri VM. Fifty years of research in ARDS. Is extracorporeal circulation the future of acute respiratory distress syndrome management? Am J Respir Crit Care Med 2017; 195: 1161–70. 3 Zapol WM, Snider MT, Hill JD, et al. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA 1979; 242: 2193–96 4 Morris AH, Wallace CJ, Menlove RL, et al. Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO 2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med 1994; 149: 295–305. 5 Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009; 374: 1351–63. 6 Combes A, Bréchot N, Luyt CE, Schmidt M. Indications for extracorporeal support: why do we need the results of the EOLIA trial? Med Klin Intensivmed Notfmed 2018; 113: 21–25. 7 Zwischenberger JB, Lynch JE. Will CESAR answer the adult ECMO debate? Lancet 2009; 374: 1307–08. 8 Combes A, Hajage D, Capellier G, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med 2018; 378: 1965–75. Time to act on injectable-free regimens for children with multidrug-resistant tuberculosis We read with interest the study by Kathryn Schnippel and colleagues, 1 showing good efficacy and low toxicity associated with bedaquiline use in adults with rifampicin-resistant tuberculosis. An interim analysis from endTB, released on July 13, 2018, evaluating the use of bedaquiline and delamanid in more than 1000 patients, has also demonstrated the safety and efficacy of these new drugs. 2 The tide appears to be turning, and in June, 2018, the South African Department of Health announced that bedaquiline will now replace second-line injectable agents in the routine treatment of all patients with rifampicin-resistant or multidrug-resistant (MDR) tuberculosis aged 12 years and older. 3 Andy Crump, TDR, WHO/SPL