Purpose of review 

Venovenous extracorporeal membrane oxygenation (VV-ECMO) provides gas exchange for patients with advanced respiratory failure who cannot maintain adequate oxygenation or carbon dioxide (CO₂) clearance through conventional mechanical ventilation. This review examines clinical applications of VV-ECMO with a focus on optimizing oxygen delivery and CO₂ removal.

Recent findings 

Over the past two decades, VV-ECMO utilization has expanded, now serving as a bridge to recovery in cases of severe hypoxemic and hypercapnic respiratory failure, as procedural support, and as a bridge to lung transplantation. Recent data have corroborated the role of VV-ECMO in managing acute respiratory distress syndrome (ARDS), and guidelines from the American Thoracic Society (ATS) and the European Society of Intensive Care Medicine (ESICM) now recommend it be considered for severe ARDS.

Summary 

This review aims to provide insights into the evolving role of VV-ECMO in the management of critical respiratory failure. Key determinants of oxygenation are discussed, particularly optimizing the ratio of VV-ECMO blood flow to cardiac output (CO). We analyze factors influencing CO₂ clearance and review available VV-ECMO configurations and their effects on gas exchange. We discuss practical targets for oxygenation and CO₂ removal in VV-ECMO, along with adjunctive techniques for refractory hypoxemia and hypercapnia.