Introduction: Advancements in extracorporeal membrane oxygenation (ECMO) have reshaped the landscape of critical care, enabling lung rest and support in severe respiratory failure. However, ventilator management during ECMO remains an area of evolving practice with no universally accepted standard. While traditional lung-protective strategies dominate, novel approaches aimed at further minimizing ventilator-induced lung injury (VILI) and enhancing lung recovery are gaining traction. This review highlights new and rising ventilation strategies in the management of ECMO-supported patients.
Methods: A literature review was conducted using PubMed, Embase, and Cochrane databases for studies published between January 2012 and March 2024. Search terms included “ECMO,” “mechanical ventilation,” “ultraprotective ventilation,” “awake ECMO,” “spontaneous breathing,” and “adjunctive strategies.” Included studies were clinical trials, cohort studies, case series, and expert guidelines addressing novel ventilator approaches in adult patients receiving either veno-venous (VV) or veno-arterial (VA) ECMO.
Results: Emerging ECMO ventilation strategies include ultraprotective (≤4 mL/kg) and near‑apneic ventilation, as well as spontaneous breathing protocols. Early mobilization and awake ECMO allow lower sedation, preserved diaphragm function, and earlier weaning. Advanced modes like Neurally Adjusted Ventilatory Assist (NAVA) and Proportional Assist Ventilation (PAV) aim to synchronize effort while limiting lung stress. Adjuncts such as prone positioning, permissive hypercapnia, and variable ventilation may improve recruitment and oxygenation. These approaches may enhance recovery and reduce VILI, though high‑quality data are limited.
Conclusions: Ventilation management in ECMO is shifting beyond traditional lung-protective frameworks toward individualized, dynamic approaches that emphasize lung rest, patient interaction, and early recovery. Novel strategies such as ultraprotective ventilation, awake ECMO, and synchrony-promoting modes are redefining care paradigms. Further randomized trials are needed to establish the safety, efficacy, and long-term outcomes of these rising approaches.
