Table 2.

Implications of V-V ECMO treatment for PEEP management in patients with severe ARDS

Implications of V-V ECMO treatment	Implications for PEEP management
“Lung rest” strategy	Minimize VILI: Moderate PEEP levels to reduce mechanical power transmission. Inadequate low PEEP can lead to progressive alveolar collapse and increased pulmonary vascular resistance*
“Ultraprotective” tidal volume	Reduced transpulmonary pressure: Possible interaction with cyclic alveolar opening and closing (atelectrauma)
Very low lung volume due to severe disease	Limit end-tidal overdistension: Necessity of high airway pressures for significant recruitment*
High ventilation inhomogeneity	Highly variable recruitability: Possible paradoxical effects with higher PEEP levels*
Gas exchange primarily through V-V ECMO	Extracorporeal gas exchange: Reduced dependence on PEEP to ensure oxygenation
Right ventricular unloading*	Potential for moderate PEEP: Moderate PEEP to target lower airway pressures during acute cor pulmonale

V-V ECMO, veno-venous extracorporeal membrane oxygenation; PEEP, positive end-expiratory pressure; ARDS, acute respiratory distress syndrome; VILI, ventilator-induced lung injury

^* Individual responses to “ultraprotective” ventilation can vary, and effects such as lung recruitment and right ventricular unloading may be influenced by patient-specific factors