Background

Extubation during extracorporeal oxygenation (ECMO) in severe acute respiratory distress syndrome(ARDS) has not been well studied. Despite the potential benefits of this strategy, weaning from ECMO before libera‑tion from invasive mechanical ventilation remains the most frequent approach. Our aim was to evaluate the safetyand feasibility of a standardized approach for extubation during ECMO in patients with severe ARDS.

Results

We conducted a prospective observational study to assess the safety and feasibility of a standardizedapproach for extubation during ECMO in severe ARDS among 254 adult patients across 4 intensive care units (ICU)from 2 tertiary ECMO centers over 6 years. This consisted of a daily assessment of clinical and gas exchange crite‑ria based on an Extracorporeal Life Support Organization guideline, with extubation during ECMO after validationby a dedicated intensive care medicine specialist. Fifty‑four (21%) patients were extubated during ECMO, 167 (66%)did not reach the clinical criteria, and in 33 (13%) patients, gas exchange precluded extubation during ECMO. AtECMO initiation, there were fewer extrapulmonary organ dysfunctions (lower SOFA score [OR, 0.88; 95% CI, 0.79–0.98;P = .02] with similar PaO2/FiO2) when compared with patients not extubated during ECMO. Extubation during ECMO associated with shorter duration of invasive mechanical ventilation (7 (4–18) vs. 32 (18–54) days; P < .01) and of ECMO(12 (7–25) vs. 19 (10–41) days; P = .01). This was accompanied by a lower incidence of hemorrhagic shock (2 vs. 11%;P = .05), but more cannula‑associated deep vein thrombosis (49 vs. 31%; P = .02) and failed extubation (20 vs. 6%;P < .01). There were no increased major adverse events. Extubation during ECMO is associated with a lower risk of all‑cause death, independently of measured confounding (adjusted logistic regression OR 0.23; 95% confidence interval0.08–0.69, P = .008).

Conclusions

A standardized approach was safe and feasible allowing extubation during ECMO in 21% of patientswith severe ARDS, selecting patients who will have a shorter duration of invasive mechanical ventilation, ECMOcourse, and ICU stay, as well as fewer infectious complications, and high hospital survival.