Necrotizing pneumonia is a severe complication of bacterial or viral pneumonia that can lead to refractory respiratory failure in children. Extracorporeal membrane oxygenation (ECMO) has emerged as a vital rescue therapy when conventional treatments fail, primarily serving as a bridge to recovery. We describe the successful use of venovenous ECMO (VV-ECMO) in two pediatric patients diagnosed with severe necrotizing pneumonia.

The first patient, a two-year-old boy, developed necrotizing pneumonia caused by parainfluenza 3 virus. He required seven days of VV-ECMO support for refractory hypoxic hypercapnic respiratory failure. He was decannulated and then extubated on day 14 of his illness to a nasal cannula. The second patient, a five-year-old girl, was diagnosed with necrotizing pneumonia caused by Streptococcus pneumoniae and Rhinovirus. She required 30 days of VV-ECMO support. Eventually, she was decannulated and extubated on day 40 of her illness.

VV-ECMO is increasingly used in children with severe pneumonia, including necrotizing forms. Prolonged support, as in the second patient, raises complication risks. CT showed bilateral lung disease with effusions, pneumothoraces, and a possible bronchopleural fistula. Lung rest strategies and minimal ventilator settings – or extubation on ECMO – can aid recovery and manage air leaks. Despite complications like circuit clots and neurologic events, both patients recovered lung function and were discharged. ECMO duration depends on disease severity and patient response.

VV-ECMO can be an effective bridge to treat severe necrotizing pneumonia in children. Early ECMO initiation, lung rest, and targeted antibiotic therapy for active infection are crucial for better outcomes.