Copyright © American Society of Artificial Internal Organs. Unauthorized reproduction of this article is prohibited. 556 ASAIO Journal 2015 Clinical Critical Care Mortality of severe acute respiratory distress syndrome (ARDS) remains high. Once conventional mechanical ventilation fails, alternative modes of therapy are used; most of which have lim- ited evidence to support their use. No definitive guidelines exist for the management of these patients with alternate modalities of treatment. We conducted a cross-sectional national survey of 302 adult critical care training programs in the United States to understand the current preferences of intensivists regarding the use of different therapies for severe ARDS, including the use of extracorporeal membrane oxygenation (ECMO). A total of 381 responses were received: 203 critical care faculty and 174 critical care trainees. Airway pressure release ventilation was the initial choice of treatment reported by most when conven- tional mechanical ventilation strategy failed followed by inhaled nitric oxide and prone positioning. Extracorporeal membrane oxygenation availability was reported by 80% of the respon- dents at their institutions. Most respondents (83%) would con- sider ECMO in patients who fail optimal mechanical ventilation strategies, and the majority (60%) believed that ECMO use can facilitate lung protective ventilation, but few favored its use as a first-line modality. The majority of respondents reported limited knowledge of ECMO and desired specific ECMO education dur- ing training. ASAIO Journal 2015; 61:556–563. Key Words: ECMO, severe ARDS, APRV, prone positioning, inhaled nitric oxide, ECMO survey Acute respiratory distress syndrome (ARDS) is a common diagnosis in the intensive care unit (ICU) and a frequent cause of morbidity and mortality among hospitalized patients. 1 Cross- sectional studies have shown that patients with ARDS represent up to 5–20% of all mechanically ventilated patients, the major- ity of whom develop moderate-to-severe disease. 2,3 Mortality of ARDS remains high, particularly among patients with severe disease (PaO 2 to FiO 2 ratio <100 mm Hg). 4 Although changes in ventilation strategies have improved outcomes in ARDS, 5 recent evidence suggests that mortality still remains very high especially in patients with severe ARDS. 6 Moreover, despite wide recognition of lung injury associated with excessive tidal volume ventilation, studies have shown that variable adoption of ventilatory strategies in patients with ARDS may still exist. 7,8 Furthermore, there is limited evidence to support the use of different advanced therapies frequently used in ARDS such as airway pressure release ventilation (APRV), inhaled nitric oxide (iNO), extracorporeal membrane oxygenation (ECMO), and high-frequency oscillatory ventilation (HFOV), and currently, there are no widely accepted guidelines to help standardize the approach to patients with severe ARDS. Recent advances in ECMO technology, and improved out- comes among patients supported with ECMO, 9,10 have resulted in a renewed interest in the use of this therapy for selected patients with severe ARDS. 10,11 Similarly, a recent study sug- gesting that ventilation in the prone positioning (PP) improves mortality for patients with severe ARDS 12 has prompted many to debate whether ECMO and/or PP should be the preferred therapies for patients with severe ARDS. This study was aimed to ascertain current practices for patients with severe ARDS at academic institutions in the United States. In addition, we intended to understand the cur- rent preferences of intensivists regarding the use of different therapies for severe ARDS, including the use of ECMO. Material and Methods Definition of Severe ARDS For purposes of this survey research, the following definition was used and provided to all participants of the study: 1) PaO 2 to FiO 2 ratio less than or equal to 100 mm Hg; 2) use of high levels of positive end-expiratory pressure more than or equal to 15 cm water; and 3) use of high FiO 2 more than or equal to 0.8 Development of the Survey After obtaining institutional review board (IRB) approval at the University of Alabama at Birmingham (IRB no. E140108008), N.S.S. developed the initial survey instrument with 17 questions using iterative process. It was then reviewed by K.W., D.B., and E.D.G. and changes were made with the addition of two more questions. Three researchers, E.D.G., K.W., and D.B. are experienced clinicians in the field of ECMO and lung transplantation. The initial questionnaire consisted of Use of ECMO in the Management of Severe Acute Respiratory Distress Syndrome: A Survey of Academic Medical Centers in the United States NIRMAL S. SHARMA,* KEITH M. WILLE,* DEGUI ZHI,† VICTOR J. THANNICKAL,* DANIEL M. BRODIE,‡ CHARLES W. HOOPES,§ AND ENRIQUE DIAZ-GUZMAN* Copyright © 2015 by the American Society for Artificial Internal Organs DOI: 10.1097/MAT.0000000000000245 From the *Division of Pulmonary, Allergy and Critical Care Medi- cine, University of Alabama at Birmingham, Birmingham, Alabama; †Department of Biostatistics, Ryals School Public Health, University of Alabama at Birmingham, Birmingham, Alabama; ‡Division of Pul- monary, Critical Care, and Sleep Medicine, Columbia University, New York, New York; and §Department of Cardiothoracic Surgery, Univer- sity of Kentucky, Lexington, Kentucky. Submitted for consideration December 2014; accepted for publica- tion in revised form April 2015. Disclosure: The authors have no conflicts of interest to report. Correspondence: Enrique Diaz-Guzman, Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birming- ham, 1102 Jefferson Tower, 625, 19th Street South, Birmingham, AL 35294. Email: diaze@uab.edu.