Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Extracorporeal membrane oxygenation in severe respiratory failure

  Severe respiratory failure can progress quickly from high-flow oxygen and non-invasive ventilation to invasive mechanical ventilation, profound hypoxemia, and circulatory instability. In carefully selected patients, extracorporeal membrane oxygenation (ECMO) provides temporary support while the lungs recover or a longer-term treatment pathway is arranged.

  ECMO does not cure pneumonia, acute respiratory distress syndrome (ARDS), pulmonary hemorrhage, or other underlying conditions. Instead, it supports gas exchange and reduces the pressure placed on injured lungs, giving clinicians time to treat the cause. Its use requires rapid assessment, specialized equipment, and a coordinated multidisciplinary team.

  The topic is central to modern respiratory and critical care practice, including the kind of specialist exchange promoted through APSR and KATRD congress activities. Decisions often need to be made before irreversible organ injury develops, making referral pathways and institutional readiness especially important.

  How ECMO supports failing lungs

  Venovenous ECMO (VV-ECMO) is generally used when the primary problem is respiratory failure with adequate cardiac function. Blood is drained from the venous circulation, passed through an oxygenator where carbon dioxide is removed and oxygen is added, and returned to the venous system. The patient’s heart then circulates the oxygenated blood.

  This approach can permit “lung rest” ventilation, using lower tidal volumes, reduced airway pressures, and carefully controlled oxygen exposure. Such a strategy may limit ventilator-induced lung injury while antibiotics, diuresis, immunomodulation, or treatment of another underlying cause takes effect.

  Venoarterial ECMO (VA-ECMO) has a different purpose. It provides both circulatory and respiratory support and may be considered when severe cardiac dysfunction, cardiogenic shock, or cardiac arrest accompanies respiratory collapse. Selecting the appropriate configuration is a specialist decision based on hemodynamics, echocardiography, gas exchange, and the cause of deterioration.

  When conventional treatment is no longer enough

  ECMO is considered when potentially reversible respiratory failure remains life-threatening despite optimized conventional care. Clinicians review ventilation settings, prone positioning, neuromuscular blockade when appropriate, fluid balance, infection treatment, and other evidence-based interventions before escalating to extracorporeal support.

  Persistent severe hypoxemia, uncompensated respiratory acidosis, dangerously high plateau pressures, or inability to provide adequate ventilation without causing additional lung injury can support referral. The exact thresholds vary by protocol and clinical context. Trends are often more informative than a single blood gas result.

  Timing is critical. Delayed referral may allow kidney, liver, brain, or cardiovascular injury to become established. Referral that occurs too early can expose a patient to an invasive therapy that may not be necessary. A specialist ECMO center can help assess candidacy even when transfer or cannulation is not ultimately required.

  Selecting patients and planning the circuit

  Patient selection considers reversibility, biological age, functional status, comorbid illness, duration of mechanical ventilation, and the presence of non-pulmonary organ failure. Severe chronic disease does not automatically exclude ECMO, but it can influence expected benefit, rehabilitation potential, and the goals agreed upon with the patient and family.

  Cannulation may be performed at the receiving center or, in some systems, by a mobile retrieval team. Ultrasound guidance, anticoagulation planning, vascular assessment, and imaging help reduce procedural risk. The circuit must be monitored continuously for flow problems, oxygenator dysfunction, clot formation, and changes in patient physiology.

  Clinical consideration	Why it matters
  Reversible cause	ECMO is most useful when lung or cardiac function may recover
  Gas exchange	Persistent hypoxemia or severe acidosis despite optimized care supports escalation
  Mechanical ventilation duration	Prolonged injurious ventilation may reduce the likelihood of benefit
  Other organ systems	Kidney, liver, neurological, and cardiovascular status affect prognosis
  Treatment goals	Families and clinicians need a clear plan for recovery, limitation, or transition

  Managing patients during extracorporeal support

  Once ECMO begins, care extends far beyond oxygen delivery. Ventilator settings are adjusted to protect the lungs, while blood flow, sweep gas, anticoagulation, hemoglobin, acid-base balance, and temperature are reviewed frequently. Sedation is reduced when safe, and early mobilization may be considered in selected patients.

  Bleeding and thrombosis are major competing risks. Cannula-site bleeding, intracranial hemorrhage, gastrointestinal bleeding, oxygenator clotting, and circuit embolization require immediate attention. Infection prevention, pressure injury prevention, nutritional support, delirium management, and rehabilitation should be integrated into daily care rather than postponed until decannulation.

  Prone positioning can sometimes be used during VV-ECMO, although it demands careful coordination around cannulas and monitoring lines. Renal replacement therapy may be required for acute kidney injury or fluid overload. Multidisciplinary rounds help align respiratory, intensive care, nursing, perfusion, infectious disease, surgical, and rehabilitation priorities.

  Recovery, weaning, and longer-term care

  Signs of recovery may include improved lung compliance, reduced oxygen requirements, better radiographic findings, and the ability to maintain gas exchange with lower ECMO support. Weaning is a gradual process that may involve reducing sweep gas, assessing native lung function, and confirming that the patient can tolerate a safe trial without extracorporeal assistance.

  Decannulation is only one stage of recovery. Patients may face muscle weakness, critical illness neuropathy, swallowing problems, cognitive changes, anxiety, depression, and persistent breathlessness. Follow-up should address pulmonary rehabilitation, nutrition, medication review, vaccination, and evaluation for residual fibrosis or another chronic respiratory condition.

  ECMO should also be distinguished from non-invasive support used outside the intensive care setting. For background on managing stable or progressive chronic respiratory disease, clinicians can review this non-invasive ventilation guidance. The appropriate treatment depends on the patient’s physiology, goals, and response over time.

  Building a reliable referral pathway

  A hospital’s ability to use ECMO safely depends on preparation before an emergency occurs. Clear escalation criteria, direct access to a regional ECMO center, standardized transport procedures, and simulation training can reduce delays. Staff should know which data to gather during referral, including ventilator settings, blood gases, imaging, vasoactive drug use, and the timeline of deterioration.

  Communication with families should be honest and continuous. Clinicians need to explain the purpose of ECMO, possible complications, uncertain outcomes, and the conditions under which support might be withdrawn. Shared decisions are particularly important when pre-existing illness or prolonged organ failure makes recovery less likely.

  Practical priorities for respiratory and critical care teams include:

  • Identify severe ARDS or refractory respiratory failure early and contact an ECMO center before deterioration becomes irreversible.
  • Optimize lung-protective ventilation, prone positioning, infection treatment, and hemodynamic support while referral is underway.
  • Assess reversibility, comorbidities, duration of ventilation, and neurological or multi-organ injury rather than relying on a single threshold.
  • Establish protocols for anticoagulation, bleeding management, transport, rehabilitation, and family communication.
  • Review every ECMO case through multidisciplinary audit to improve selection, safety, and continuity of care.

  Effective ECMO programs are built on timely recognition, disciplined supportive care, and collaboration between referring hospitals and specialist centers. Respiratory conferences associated with APSR and KATRD provide valuable opportunities to examine evolving evidence, share regional experience, and strengthen the systems required for complex rescue therapy. Explore current guidance, connect with respiratory specialists, and develop a local pathway so that eligible patients can reach expert assessment when every hour matters.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)