Extubate Before Venovenous Extracorporeal Membranous Oxygenation Decannulation or Decannulate While Remaining on the Ventilator? The EuroELSO 2019 Weaning Survey

Patients who receive venovenous extracorporeal membrane oxygenation (VV ECMO) support upon failure of invasive mechanical ventilation (IMV) and other adjuncts, including low tidal volume, prone positioning, adjusted positive end-expiratory pressure, and lung recruitment maneuvers, typically remain on IMV after VV ECMO commencement. Once both IMV and VV ECMO support are initiated, it is unclear which modality should be weaned first. Moreover, the optimal IMV settings, risk versus benefits of early spontaneous breathing, and optimal timing of VV ECMO weaning practices are yet to be defined. In addition, although the practice of liberation from IMV during ECMO has been increasing, the data concerning the weaning processes from ECMO and IMV are limited.

The variation in the management strategies between centers may be influenced by case mix, experience and volume. Only 32% of providers perceive that their center pursues extubation before weaning ECMO; 31% of participants report their weaning strategy to be similar regardless of reason for respiratory failure, whereas the remaining centers tend to use a varied approach from case to case. Some patients cannot be safely extubated while on VV ECMO while others are clear candidates. Adequacy of participation in pulmonary hygiene (deep breath, cough) is paramount and limited sedation with adequate pain and anxiety management are required. Ambulation is the Elysian ideal. We suggest further research on how clinicians and/or center decide in favor of weaning IMV before ECMO.

There is also a need for research to define whether weaning from ECMO before weaning from ventilation is superior to weaning from ventilation before liberation from ECMO. Very likely, different patient populations will benefit from an individualized approach.