Prolonged Duration ECMO for ARDS: Futility, Native Lung Recovery, or Transplantation?

Extracorporeal membrane oxygenation (ECMO) is recommended as a treatment
modality for severe acute respiratory distress syndrome (PaO2/FiO2 ≤
100 mm Hg with positive end-expiratory pressure ≥ 5 cm H2O) as defined
by the Berlin definition. The reported usual duration of ECMO in these
patients is 7-10 days. However, increasing reports of prolonged duration
ECMO (>14 days) for respiratory failure document survival rates of
50-70% with native lung recovery, and ECMO bridge to lung
transplantation has been performed at many centers. At present, there
are no established national criteria for when to consider futility or
lung transplantation in adult patients requiring ECMO for acute
respiratory failure. We report a case of prolonged duration
venovenous-ECMO (1,347 hours, 56.13 days), with native lung recovery and
discuss treatment strategies to optimize native lung recovery in ECMO
patients. The lung may have unexpected regenerative capacity with native
lung recovery after prolonged mechanical support, similar to acute
kidney injury and native renal recovery. We recommend redefining
irreversible lung injury and futility in ECMO.