Pulmonary protection and management during extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation is a supportive technology deployed to either maintain gas exchange in the setting of lung failure or provide end-organ perfusion for patients in circulatory failure. In both scenarios, patient survival is dependent on either recovery of native organ function or successful bridge to definitive therapy such as solid organ transplant. In the case of extracorporeal support of lung failure, patient management focused on limiting further lung injury and promoting organ recovery are required for successful clinical outcomes. Initiation of extracorporeal support provides for gas exchange independent of lung function and enables a focus on use of the ventilator as a means of optimizing the lung state to promote organ recovery. This chapter details the pathobiology of the lung and describes the mechanisms of ventilator-induced lung injury prior to presenting an approach to optimizing lung state to enhance the likelihood of patient survival. The lack of definitive randomized trials to support a specific approach requires instead an approach based on pathophysiological reasoning and clinical judgment until further evidence is available to validate a clinical care paradigm.