ECMO without intubation in ARDS failed in a quarter to two-fifths, and failure carried high mortality

Design

International retrospective cohort, 14 centres in 8 countries

Population

307 adults with ARDS on ECMO without invasive ventilation (113 primary awake, 194 extubated)

Primary outcome

90-day mortality after ECMO initiation

Effect

30.1% (awake) and 14.9% (extubated); strategy failure HR 5.95 and 7.67 for death

This international retrospective cohort from 14 centres in eight countries (2015 to 2024) included 307 adults with ARDS supported by ECMO without invasive mechanical ventilation: 113 had primary awake ECMO to avoid intubation, and 194 were extubated while on ECMO.

Ninety-day mortality was 30.1% with primary awake ECMO and 14.9% with extubated ECMO. Strategy failure, meaning intubation or reintubation, occurred in 40.7% and 24.2% respectively, mostly within the first ten days. Failure was strongly associated with death (HR 5.95 for awake ECMO, 7.67 for extubated ECMO). Leading causes were worsening respiratory failure, agitation or delirium in the awake group, and inability to clear secretions in the extubated group.

Avoiding ventilation on ECMO is attractive, but this shows it suits selected patients in expert centres. The first ten days need close watching, with a low threshold to intubate if secretions or agitation become unmanageable.

• Awake or extubated ECMO in ARDS is for selected patients in experienced ECMO centres.
• Most failures occur within the first 10 days; review daily for worsening gas exchange, agitation and secretion load.
• Poor cough and secretion clearance predict failure after extubation on ECMO.
• Delay from ICU admission to cannulation was associated with higher mortality in the awake ECMO group.

Why it matters

It sets realistic expectations for an increasingly used strategy and marks when to abandon it.

Don't overread it

This is a retrospective cohort of selected patients; it cannot say whether avoiding intubation is better than standard ventilation.

The statistics, in plain English

Hazard ratios of 6 to 8 mean patients whose strategy failed had a much higher death rate, but failure partly reflects how sick patients were; it is not proof that failure itself caused death. The two groups were selected differently, so their mortality rates should not be compared directly.

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