Weaning from veno-venous extracorporeal membrane oxygenation: how I do it

Abstract

Veno-venous extracorporeal membrane oxygenation (VV ECMO) is a rescue treatment for acute respiratory distress syndrome (ARDS) failing protective mechanical ventilation. It temporarily provides proper gas exchange: hypoxia is treated by adjusting the blood flow rate and fraction in spired oxygen over the ventilator (FiO2) on the extracorporeal membrane oxygenation (ECMO) circuit while CO2 removal is regulated by the ECMO fresh gas flow. Therefore, ventilator settings can be gradually reduced allowing the lungs to rest and recover. Nowadays, indications for ECMO referral and implantation are clearly formulated; on the contrary, little evidence currently exists to guide the process of weaning from ECMO support, especially concerning the timing during the course of lung healing. Therefore, indications to stop ECMO are less well standardized so that in clinical trials extracorporeal assistance is generally continued until lung recovery, with neither specific nor homogenous criteria for withdrawal. Notably, in almost all papers dealing with data on VV ECMO support, the management of weaning and the weaning procedure itself are not described. The aim of this paper is to make a picture of VV ECMO weaning, as it is performed in three European large volume intensive care units (ICUs) which represent referral centers for VV ECMO treatment. We focused on data concerning the timing of VV ECMO weaning and parameters at the time of weaning, in order to assess adequacy and safety of VV ECMO removal.

Keywords: Weaning; extracorporeal membrane oxygenation (ECMO); veno-venous (VV).

Conflict of interest statement

Conflicts of Interest: LM Broman, MV Malfertheiner and F Pappalardo are members of the independent research consortium European ECMO Advisory Board, the EuroELSO Workgroup for Innovative Technologies, and the Medical Advisory Board of Eurosets Medical Srl, Medolla, Italy. The other author has no conflicts of interest to declare.

Figures

Figure 1

Veno-venous ECMO weaning starts with improvement of the natural lung. Improving gas exchange should be monitored and the weaning process should focus on keeping the balance between natural and membrane lung. ECMO, extracorporeal membrane oxygenation.