Ventilator settings during veno-venous ECMO in ARDS patients.

Abstract

Veino-venous extracorporeal membrane oxygenation (VV-ECMO) allows oxygenation and decarboxylation in case of refractory acute respiratory distress syndrome. Invasive ventilation in patients under VV-ECMO aims at limiting ventilator induced lung injuries, by decreasing tidal volume, respiratory frequency and pressure levels. There is currently a lack of randomized controlled studies evaluating invasive ventilation strategies under VV-ECMO.  The ventilatory strategy during VV-ECMO is based on a "ultra-protective" ventilation, guided by the experience of each ECMO center. In its recommendations published in 2020, the Extracorporeal Life Support Organization proposes an initial ventilator setting in a pressure mode with a PEEP of 15 cmH₂O, an inspiratory pressure of 25 cmH₂O and a respiratory frequency of 5 cycles per minute. The intensity of ventilation can be increased to optimize gas exchange in case of persistent hypoxemia under VV-ECMO, or decreased in order to be more protective. The objective of this article is to review frequently asked questions regarding invasive mechanical ventilation during the run of VV-ECMO.