Fig. 1.

Three different modalities of ECLS for acute respiratory distress syndrome. A Femoro-jugular venovenous extracorporeal membrane oxygenation (VV-ECMO) which enables full oxygenation and carbon dioxide removal in the acute phase of ARDS. Typical mechanical ventilation settings (EOLIA settings) aim to further protect the lung by reducing VT, RR, and ∆P; B Dual-lumen jugular VV-ECMO is an alternative cannulation strategy; C Extra-corporeal CO₂ removal, which may facilitate lung-protective ventilation by allowing a reduction of VT, Pplat, RR, ∆P and mechanical power (SUPERNOVA pilot settings) by ensuring partial carbon dioxide removal with marginal oxygenation in mild-to-moderate ARDS. VCV volume-controlled ventilation, PEEP positive end-expiratory pressure, VT tidal volume, Pplat plateau pressure, BIPAP/APRV biphasic positive airway pressure/airway pressure release ventilation, RR respiratory rate, ∆P driving pressure, Fr French, ARDS acute respiratory distress syndrome, ECLS extracorporeal life support, MV mechanical ventilation, FdO₂ fraction on oxygen in the sweep gas, MO, membrane oxygenator, Qecmo (Q_E) ECMO flow in L/min. Major changes between the three settings are highlighted in bold font. ^a Modified EOLIA settings with a set RR lower than in EOLIA. Decreasing respiratory rate (< 10–15 breaths/min) to reduce mechanical power seems desirable, although it may be achieved in most ARDS patients only with deep sedation and neuromuscular blockade