How Should I Ventilate a Patient on ECMO or ECCO2R?

Abstract

The timing and the outcome of extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) have received considerable attention, but very little has been given to mechanical ventilation during ECMO. Although the impact of a protective ventilation has been markedly demonstrated for non-ECMO-supported ventilated patients, there is no consensus with ECMO yet. Consequently, ventilation management during ECMO is based on clinician preference, experience of centers with high case volumes, and local resource availability. Nevertheless, there is a physiological rationale, mainly based on animal studies, to advise an “ultraprotective” ventilation strategy with ECMO. This strategy will combine a tidal volume reduction (< 6 ml/ kg predicted body weight) and a plateau pressure reduction (< 25 cmH₂O) with high positive end-expiratory pressure level to provide lung recruitment (>10 cmH₂O). Future studies are urgently required to determine the best practice of mechanical ventilation during ECMO and its impact on patient-centered outcomes.