Figure 1.

A flow chart of ventilator settings after ECMO starting. Sequence of setting changes follow literature common procedure. Tidal volume (V_T) is decrease targeting a safe plateau airway pressure or targeting a predefined V_T value (ultra-protective ventilation). After adjusting V_T, respiratory rate (RR) may be changed according to PaCO₂/pH or target to a fixed low level (5–10 bpm). Decrease of V_T and RR are allowed by CO₂ removal mainly modulated by acting on sweep gas flow (GF). This is feasible both with ECMO or ECCO₂R. When high ECMO blood flows (BF) are used, oxygenation is supported, and FiO₂ may be decreased. PEEP may either be decreased if a total lung rest strategy is used, or may be set to avoid derecruitment associated to low V_T ventilation (black dotted line). ↓, decrease; ↑, increase. ECMO, extracorporeal membrane oxygenation.