Background: Extubation while receiving V-V ECMO is being considered earlier for patients with respiratory failure. This can facilitate early mobilization, participation in physical therapy, and reduce the potential consequences of prolonged mechanical ventilation and analgosedation. When confronted with the decision of extubation vs tracheostomy in a V-V ECMO patient, there is a paucity of evidence to fully support one decision over the other. Our institution has created an algorithmic approach when faced with this conflict to help guide our management. We discuss three cases that highlight the use of this approach.

Methods: Three patients were selected to discuss the potential benefit of utilizing an algorithmic approach to extubation.

Results: All three patients would have met criteria for extubation. One patient had a tracheostomy performed instead of extubation, which resulted in excessive positive pressure and worsening bronchopleural fistulas, ultimately requiring re-cannulation and initiation on V-V ECMO. The other two had improved clinical outcomes, despite similar pathophysiology and clinical pictures.

Discussion

We often find ourselves in conflict when patients are showing improvement and we are faced with the decision to decannulate, extubate, or perform a tracheostomy. There is evidence supporting lack of orotracheal intubation in these patients, but minimal evidence to support tracheostomy over extubation. As we have implemented an algorithm in our decisions, based on respiratory mechanics, we are finding that some patients may certainly benefit from the removal of positive pressure to allow for parenchymal healing. Further studies are needed to validate and explore this approach.