Essential Topics in the Management of Venovenous Extracorporeal Membrane Oxygenation in COVID-19 Acute Respiratory Distress Syndrome

For more than a year, patients around the world have dealt with the effects of coronavirus disease 2019 (COVID-19) infection, including acute respiratory distress syndrome (ARDS). Most patients with COVID-19 infection remain asymptomatic; however, approximately 5%-to-20% of patients develop severe ARDS requiring admission to the intensive care unit (ICU) and mechanical ventilation. Strategies to manage this subset of patients include low-stretch mechanical ventilation, prone positioning, and neuromuscular blockade. When these strategies fail due to refractory hypoxemia, severe hypercarbia, or requirement for severely injurious mechanical ventilation (MV) settings, venovenous extracorporeal membrane oxygenation (VV ECMO) can be an option. Venovenous ECMO allows lung rest ventilator settings, may permit safely waking the patient up to start physical therapy, and gives the patient time as a bridge to recovery or lung transplantation. Management of mechanical circulatory support in COVID-19 ARDS requires a highly resourced multidisciplinary ICU team and the ability to nimbly develop protocols for care for this new patient population. Here the authors discuss some unique aspects of care using VV ECMO management in COVID-19 ARDS.