Respiratory Failure: Indications for ECMO

Extracorpreal membrane oxygenation is a temporizing mechanical support to heart or lung function in the setting of cardiopulmonary failure. In the setting of severe respiratory failure, patients that may benefit from and/or have an indication for ECMO are described in the Extracorporeal Life Support Organization Respiratory Failure Supplement to ESLO General Guideline, December 2013:


  • In hypoxic respiratory failure due to any cause (primary or secondary) ECLS should be considered when the risk of mortality is 50% or greater, and is indicated when the risk of mortality is 80% or greater. 
  1. 50% mortality risk is associated with a PaO2/FiO2 < 150 on FiO2 > 90% and/or Murray score 2-3. Murray Score Calculator
  2. 80% mortality risk is associated with a PaO2/FiO2 < 100 on FiO2> 90% and/or Murray score 3-4 despite optimal care for 6 hours or more. 
  • CO2 retention on mechanical ventilation despite high Pplat (>30 cm H2O) 
  • Severe air leak syndromes 
  • Need for intubation in a patient on lung transplant list 
  • Immediate cardiac or respiratory collapse (PE, blocked airway, unresponsive to optimal care)

There are no absolute contraindications to ECLS, as each patient is considered individually with respect to risks and benefits. There are conditions, however, that are associated with a poor outcome despite ECLS, and can be considered relative contraindications.

  • Mechanical ventilation at high settings (FiO2 > .9, P-plat > 30) for7 days or more 
  • Major pharmacologic immunosuppression (absolute neutrophil count <400/mm3) 
  • CNS hemorrhage that is recent or expanding 
  • Non recoverable comorbidity such as major CNS damage or terminal malignancy 
  • Age: no specific age contraindication but consider increasing risk with increasing age

Additional Links:
Extracorporeal Life Support Organization Guidelines
NHLBI ARDS Network Ventilator Protocol
ECMO Review of Lifesaving Technology, Journal of Thoracic Disease, July 2015

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