Extracorporeal life support for adults with acute respiratory distress syndrome

Alain Combes, Matthieu Schmidt, Carol L. Hodgson, Eddy Fan, Niall D. Ferguson, John F. Fraser, Samir Jaber, Antonio Pesenti, Marco Ranieri, Kathryn Rowan, Kiran Shekar, Arthur S. Slutsky, Daniel Brodie

Research output: Contribution to journalReview articlepeer-review


Extracorporeal life support (ECLS) can support gas exchange in patients with the acute respiratory distress syndrome (ARDS). During ECLS, venous blood is drained from a central vein via a cannula, pumped through a semipermeable membrane that permits diffusion of oxygen and carbon dioxide, and returned via a cannula to a central vein. Two related forms of ECLS are used. Venovenous extracorporeal membrane oxygenation (ECMO), which uses high blood flow rates to both oxygenate the blood and remove carbon dioxide, may be considered in patients with severe ARDS whose oxygenation or ventilation cannot be maintained adequately with best practice conventional mechanical ventilation and adjunctive therapies, including prone positioning. Extracorporeal carbon dioxide removal (ECCO2R) uses lower blood flow rates through smaller cannulae and provides substantial CO2 elimination (~ 20–70% of total CO2 production), albeit with marginal improvement in oxygenation. The rationale for using ECCO2R in ARDS is to facilitate lung-protective ventilation by allowing a reduction of tidal volume, respiratory rate, plateau pressure, driving pressure and mechanical power delivered by the mechanical ventilator. This narrative review summarizes physiological concepts related to ECLS, as well as the rationale and evidence supporting ECMO and ECCO2R for the treatment of ARDS. It also reviews complications, limitations, and the ethical dilemmas that can arise in treating patients with ECLS. Finally, it discusses future key research questions and challenges for this technology.

Original languageEnglish (US)
Pages (from-to)2464-2476
Number of pages13
JournalIntensive Care Medicine
Issue number12
StatePublished - Dec 2020
Externally publishedYes


  • Acute respiratory failure
  • Extracorporeal membrane oxygenation
  • Mechanical ventilation
  • Outcome

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine


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