Review

. 2022 Oct;48(10):1326-1337.

doi: 10.1007/s00134-022-06815-w. Epub 2022 Aug 9.

Respiratory indications for ECMO: focus on COVID-19

Alexander Supady^{1

2}, Alain Combes^#^{3

4}, Ryan P Barbaro⁵, Luigi Camporota^{6

7}, Rodrigo Diaz⁸, Eddy Fan^{9

10

11}, Marco Giani¹², Carol Hodgson^{13

14

15

16}, Catherine L Hough¹⁷, Christian Karagiannidis¹⁸, Matthias Kochanek¹⁹, Ahmed A Rabie²⁰, Jordi Riera²¹, Arthur S Slutsky^#^{9

22}, Daniel Brodie^#^{23

24}

Affiliations

¹ Interdisciplinary Medical Intensive Care, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
² Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany.
³ Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France.
⁴ Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France.
⁵ Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
⁶ Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.
⁷ Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK.
⁸ Programa de Oxigenación Por Membrana Extracorpórea, Hospital San Juan de Dios Santiago, Santiago, Chile.
⁹ Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
¹⁰ Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
¹¹ Department of Medicine, University Health Network and Sinai Health System, Toronto, ON, Canada.
¹² Department of Emergency and Intensive Care, School of Medicine and Surgery, University of Milano-Bicocca, ASST Monza, Monza, Italy.
¹³ Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia.
¹⁴ School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
¹⁵ Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia.
¹⁶ University of Melbourne, Parkville, VIC, Australia.
¹⁷ Department of Medicine, Oregon Health and Science University, Portland, OR, USA.
¹⁸ Department of Pneumology and Critical Care Medicine, ARDS and ECMO Centre, Cologne-Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany.
¹⁹ Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, University Hospital Cologne, Cologne, Germany.
²⁰ Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia.
²¹ Departament de Medicina Intensiva, Hospital Universitari Vall d'Hebron, SODIR, Vall d'Hebron Institut de Recerca, Barcelona, Spain.
²² Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
²³ Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, 622W168th St, PH 8 East, Room 101, New York, NY, 10032, USA. hdb5@cumc.columbia.edu.
²⁴ Center for Acute Respiratory Failure, Columbia University Medical Center, New York, USA. hdb5@cumc.columbia.edu.

^# Contributed equally.

PMID: 35945343
PMCID: PMC9362963
DOI: 10.1007/s00134-022-06815-w

Review

Respiratory indications for ECMO: focus on COVID-19

Alexander Supady et al. Intensive Care Med. 2022 Oct.

. 2022 Oct;48(10):1326-1337.

doi: 10.1007/s00134-022-06815-w. Epub 2022 Aug 9.

Authors

Affiliations

¹ Interdisciplinary Medical Intensive Care, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
² Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany.
³ Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France.
⁴ Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France.
⁵ Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
⁶ Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.
⁷ Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK.
⁸ Programa de Oxigenación Por Membrana Extracorpórea, Hospital San Juan de Dios Santiago, Santiago, Chile.
⁹ Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
¹⁰ Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
¹¹ Department of Medicine, University Health Network and Sinai Health System, Toronto, ON, Canada.
¹² Department of Emergency and Intensive Care, School of Medicine and Surgery, University of Milano-Bicocca, ASST Monza, Monza, Italy.
¹³ Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia.
¹⁴ School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
¹⁵ Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia.
¹⁶ University of Melbourne, Parkville, VIC, Australia.
¹⁷ Department of Medicine, Oregon Health and Science University, Portland, OR, USA.
¹⁸ Department of Pneumology and Critical Care Medicine, ARDS and ECMO Centre, Cologne-Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Cologne, Germany.
¹⁹ Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center of Integrated Oncology Aachen Bonn Cologne Dusseldorf, University of Cologne, University Hospital Cologne, Cologne, Germany.
²⁰ Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia.
²¹ Departament de Medicina Intensiva, Hospital Universitari Vall d'Hebron, SODIR, Vall d'Hebron Institut de Recerca, Barcelona, Spain.
²² Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
²³ Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, 622W168th St, PH 8 East, Room 101, New York, NY, 10032, USA. hdb5@cumc.columbia.edu.
²⁴ Center for Acute Respiratory Failure, Columbia University Medical Center, New York, USA. hdb5@cumc.columbia.edu.

^# Contributed equally.

PMID: 35945343
PMCID: PMC9362963
DOI: 10.1007/s00134-022-06815-w

Abstract

Extracorporeal membrane oxygenation (ECMO) is increasingly being used for patients with severe respiratory failure and has received particular attention during the coronavirus disease 2019 (COVID-19) pandemic. Evidence from two key randomized controlled trials, a subsequent post hoc Bayesian analysis, and meta-analyses support the interpretation of a benefit of ECMO in combination with ultra-lung-protective ventilation for select patients with very severe forms of acute respiratory distress syndrome (ARDS). During the pandemic, new evidence has emerged helping to better define the role of ECMO for patients with COVID-19. Results from large cohorts suggest outcomes during the first wave of the pandemic were similar to those in non-COVID-19 cohorts. As the pandemic continued, mortality of patients supported with ECMO has increased. However, the precise reasons for this observation are unclear. Known risk factors for mortality in COVID-19 and non-COVID-19 patients are higher patient age, concomitant extra-pulmonary organ failures or malignancies, prolonged mechanical ventilation before ECMO, less experienced treatment teams and lower ECMO caseloads in the treating center. ECMO is a high resource-dependent support option; therefore, it should be used judiciously, and its availability may need to be constrained when resources are scarce. More evidence from high-quality research is required to better define the role and limitations of ECMO in patients with severe COVID-19.

Keywords: ARDS; Acute respiratory distress syndrome; COVID-19; ECMO; Extracorporeal circulation; Extracorporeal membrane oxygenation; Resource limitations; Respiratory failure.

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Conflict of interest statement

All authors have completed the ICMJE form (available upon request from the corresponding author). AS reports research grants and lecture fees from CytoSorbents and lecture fees from Abiomed, both outside the submitted work. EF received research support from Abbott and LivaNova and consulting fees from ALung Technologies, Vasomune, Baxter and GE Healthcare. CH is supported by an Australian NHMRC Investigator grant and leads the Australian and New Zealand ECMO Registry. CK received consulting fees from Xenios/ Fresenius and Bayer. He is Chair of the German ICU Registry and President of the German Society of Medical Intensive Care. JR reports lecture and advisory fees from Medtronic and Werfen, outside the submitted work. ASS has been on medical advisory boards for Baxter and Xenios; he is Chair of the Scientific Committee of the Committee of the International ECMO Network (ECMONet). DB receives research support from ALung Technologies. He has been on the medical advisory boards for Abiomed, Xenios, Medtronic, Inspira and Cellenkos. He is the President-elect of the Extracorporeal Life Support Organization (ELSO) and the Chair of ECMONet. All other authors report no conflicts of interest.

Figures

**Fig. 1**
Mortality rates from selected ECMO cohorts during the first and later waves of the pandemic. In all reported cohorts, mortality rates were reported for variably defined later waves, compared to the first wave. Differences in outcomes between the cohorts may be, at least in part, explained by differences in inclusion and exclusion criteria (see main text for details). Broman et al. and Barbaro et al. reported data from large international cohorts confirming the observation of increasing mortality with the use of ECMO after the first wave of the pandemic. *ECMO* extracorporeal membrane oxygenation, *ARDS* acute respiratory distress syndrome, *COVID-19* coronavirus disease 2019

**Fig. 2**
Key strategies of care that may be initiated, including consideration of ECMO support in patients with ARDS (non-COVID-19 and COVID-19-related). *ECMO* extracorporeal membrane oxygenation, *ARDS* acute respiratory distress syndrome, *COVID-19* coronavirus disease 2019, *PEEP* positive end-expiratory pressure

**Fig. 3**
Patient-related and center-associated factors contributing to the risk of mortality in patients supported with venovenous ECMO, with a focus on COVID-19-related ARDS. *ECMO* extracorporeal membrane oxygenation, *ARDS* acute respiratory distress syndrome, *COVID-19* coronavirus disease 2019

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Respiratory indications for ECMO: focus on COVID-19

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Respiratory indications for ECMO: focus on COVID-19

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