Patients who receive venovenous extracorporeal membrane oxygenation (VV ECMO) support upon failure of invasive mechanical ventilation (IMV) and other adjuncts, including low tidal volume, prone positioning, adjusted positive end-expiratory pressure, and lung recruitment maneuvers, typically remain on IMV after VV ECMO commencement.^1,2 Once both IMV and VV ECMO support are initiated, it is unclear which modality should be weaned first. Moreover, the optimal IMV settings, risk versus benefits of early spontaneous breathing, and optimal timing of VV ECMO weaning practices are yet to be defined. In addition, although the practice of liberation from IMV during ECMO^3–8 has been increasing, the data concerning the weaning processes from ECMO and IMV are limited.^9,10

Differences in weaning strategies for VV ECMO are based on the preferable approach is whether to wean ECMO or not when the patient is still mechanically ventilated.¹¹ The approach to enable spontaneous breathing and early IMV weaning may prevent the complications of sedation allowing to avoid the risk of ventilation-induced lung injury and ventilator-associated pneumonia.^5,6,12,13 A pragmatic way to “wean” as soon as the tidal volume start to recover has been proposed by clinicians at the Karolinska Institute ECMO Centre in Stockholm.¹¹ Vasques et al. proposed a physiology-based assessment protocol, which combines an objective assessment of the native and artificial lung function. This method quantifies the patient’s response to a standardized weaning trial.⁹ However this strategy has not been tested in prospective trials and carries some challenges and risks in managing awake patients on ECMO. The aim of this survey was to understand current VV ECMO and IMV weaning practices globally.