Extracorporeal Membrane Oxygenation (ECMO)/Extracorporeal Carbon Dioxide Removal (ECCO2R)

  • Nicole Lena Werner
  • Pauline K. ParkEmail author


Extracorporeal membrane oxygenation (ECMO) is a means of supporting severe pulmonary and cardiac dysfunction. It stabilizes critical derangements of oxygenation and ventilation, allowing time to diagnose, treat, and recover from the underlying cause of organ failure. The extracorporeal circuit has three main components: large-bore cannulae and circuit tubing to provide access to the native circulation, an artificial membrane lung to provide gas exchange, and an active pump to facilitate perfusion. Multiple clinical studies have evaluated this technology, the strongest evidence to date supporting its use being the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial, which showed survival advantage when patients were treated with a protocol that included ECMO. Extracorporeal carbon dioxide removal (ECCO2R) is similar in concept to ECMO, but has a lower flow rate and does not significantly oxygenate the patient. It is a primary treatment for hypercarbic respiratory failure or is an adjunct to reduce potentially injurious levels of mechanical ventilator support in hypoxemic respiratory failure. Complications are common occurrences on both types of therapy. Strong institutional commitment and a team approach are critical to successful implementation. Additional randomized trials are needed to clarify the appropriate indications and best practices for these lifesaving therapies.


Extracorporeal membrane oxygenation Extracorporeal carbon dioxide removal Extracorporeal life support Respiratory failure Membrane lung Cardiac failure Bridge to transplant 


  1. 1.
    Hill JD, et al. Acute respiratory insufficiency. Treatment with prolonged extracorporeal oxygenation. J Thorac Cardiovasc Surg. 1972;64(4):551–62.PubMedGoogle Scholar
  2. 2.
    Bartlett RH, et al. Extracorporeal membrane oxygenation (ECMO) cardiopulmonary support in infancy. Trans Am Soc Artif Intern Organs. 1976;22:80–93.PubMedGoogle Scholar
  3. 3.
    Peek GJ, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009;374(9698):1351–63.CrossRefGoogle Scholar
  4. 4.
    Paden ML, Rycus PT, Thiagarajan RR. Update and outcomes in extracorporeal life support. Semin Perinatol. 2014;38(2):65–70.CrossRefGoogle Scholar
  5. 5.
    Rastan AJ, et al. Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock. J Thorac Cardiovasc Surg. 2010;139(2):302–11, 311 e1.CrossRefGoogle Scholar
  6. 6.
    Saczkowski R, et al. Centrifugal pump and roller pump in adult cardiac surgery: a meta-analysis of randomized controlled trials. Artif Organs. 2012;36(8):668–76.CrossRefGoogle Scholar
  7. 7.
    ELSO. Extracorporeal Life Support Organization Patient Specific Guidelines. A supplement to the ELSO General Guidelines (November 2013) [cited 2015; Version 1.3]. Available from:
  8. 8.
    Bartlett RH, et al. Extracorporeal circulation (ECMO) in neonatal respiratory failure. J Thorac Cardiovasc Surg. 1977;74(6):826–33.PubMedGoogle Scholar
  9. 9.
    Zimmermann M, et al. Pumpless extracorporeal interventional lung assist in patients with acute respiratory distress syndrome: a prospective pilot study. Crit Care. 2009;13(1):R10.CrossRefGoogle Scholar
  10. 10.
    UK collaborative randomised trial of neonatal extracorporeal membrane oxygenation. UK Collaborative ECMO Trail Group. Lancet. 1996; 348(9020):75–82.Google Scholar
  11. 11.
    Zapol WM, et al. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA. 1979;242(20):2193–6.CrossRefGoogle Scholar
  12. 12.
    Morris AH, et al. Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med. 1994;149(2 Pt 1):295–305.CrossRefGoogle Scholar
  13. 13.
    Hemmila MR, et al. Extracorporeal life support for severe acute respiratory distress syndrome in adults. Ann Surg. 2004;240(4):595–605; discussion 605–7.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Mols G, et al. Extracorporeal membrane oxygenation: a ten-year experience. Am J Surg. 2000;180(2):144–54.CrossRefGoogle Scholar
  15. 15.
    Lewandowski K, et al. High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation. Intensive Care Med. 1997;23(8):819–35.CrossRefGoogle Scholar
  16. 16.
    Beiderlinden M, et al. Treatment of severe acute respiratory distress syndrome: role of extracorporeal gas exchange. Intensive Care Med. 2006;32(10):1627–31.CrossRefGoogle Scholar
  17. 17.
    Peek GJ, et al. Extracorporeal membrane oxygenation for adult respiratory failure. Chest. 1997;112(3):759–64.CrossRefGoogle Scholar
  18. 18.
    Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL.Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database.Intensive Care Med. 2009;35(12):2105–14. doi:  10.1007/s00134-009-1661-7. Epub 2009 Sep 22. PMID: 19768656CrossRefGoogle Scholar
  19. 19.
    Peek GJ, et al. CESAR: conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure. BMC Health Serv Res. 2006;6:163.CrossRefGoogle Scholar
  20. 20.
    Morris AH, Hirshberg E, Miller RR, Statler KD, Hite RD. Efficacy of ECMO in H1N1 influenza: sufficient evidence? Chest. 2010;138:778–81.CrossRefGoogle Scholar
  21. 21.
    Davies A, et al. Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA. 2009;302(17):1888–95.CrossRefGoogle Scholar
  22. 22.
    Noah MA, et al. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA. 2011;306(15):1659–68.CrossRefGoogle Scholar
  23. 23.
    Miller RR, Markewitz BA, Rolfs RT, Brown SM, Dascomb KK, Grissom CK, Friedrichs MD, Mayer J, Hirschberg EL, Conklin J, Paine R, Dean NC. Clinical findings and demographic factors associated wtih ICU admission in Utah due to novel 2009 influenza A(H1N1) infection. Chest. 2010;137(4):752–8.CrossRefGoogle Scholar
  24. 24.
    Gattinoni L, et al. Low-frequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA. 1986;256(7):881–6.CrossRefGoogle Scholar
  25. 25.
    Brunet F, et al. Extracorporeal carbon dioxide removal technique improves oxygenation without causing overinflation. Am J Respir Crit Care Med. 1994;149(6):1557–62.CrossRefGoogle Scholar
  26. 26.
    Bein T, et al. A new pumpless extracorporeal interventional lung assist in critical hypoxemia/hypercapnia. Crit Care Med. 2006;34(5):1372–7.CrossRefGoogle Scholar
  27. 27.
    Bein T, et al. Lower tidal volume strategy (approximately 3 ml/kg) combined with extracorporeal CO2 removal versus ‘conventional’ protective ventilation (6 ml/kg) in severe ARDS: the prospective randomized Xtravent-study. Intensive Care Med. 2013;39(5):847–56.CrossRefGoogle Scholar
  28. 28.
    Elliot SC, et al. Pumpless extracorporeal carbon dioxide removal for life-threatening asthma. Crit Care Med. 2007;35(3):945–8.CrossRefGoogle Scholar
  29. 29.
    Burki NK, et al. A novel extracorporeal CO(2) removal system: results of a pilot study of hypercapnic respiratory failure in patients with COPD. Chest. 2013;143(3):678–86.CrossRefGoogle Scholar
  30. 30.
    Kluge S, et al. Avoiding invasive mechanical ventilation by extracorporeal carbon dioxide removal in patients failing noninvasive ventilation. Intensive Care Med. 2012;38(10):1632–9.CrossRefGoogle Scholar
  31. 31.
    Abrams DC, et al. Pilot study of extracorporeal carbon dioxide removal to facilitate extubation and ambulation in exacerbations of chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2013;10(4):307–14.CrossRefGoogle Scholar
  32. 32.
    Singer JP, et al. The impact of pretransplant mechanical ventilation on short- and long-term survival after lung transplantation. Am J Transplant. 2011;11(10):2197–204.CrossRefGoogle Scholar
  33. 33.
    Lang G, et al. Primary lung transplantation after bridge with extracorporeal membrane oxygenation: a plea for a shift in our paradigms for indications. Transplantation. 2012;93(7):729–36.CrossRefGoogle Scholar
  34. 34.
    Hammainen P, et al. Usefulness of extracorporeal membrane oxygenation as a bridge to lung transplantation: a descriptive study. J Heart Lung Transplant. 2011;30(1):103–7.CrossRefGoogle Scholar
  35. 35.
    Mason DP, et al. Should lung transplantation be performed for patients on mechanical respiratory support? The US experience. J Thorac Cardiovasc Surg. 2010;139(3):765–73 e1.CrossRefGoogle Scholar
  36. 36.
    Toyoda Y, et al. Efficacy of extracorporeal membrane oxygenation as a bridge to lung transplantation. J Thorac Cardiovasc Surg. 2013;145(4):1065–70; discussion 1070–1.CrossRefGoogle Scholar
  37. 37.
    Fuehner T, et al. Extracorporeal membrane oxygenation in awake patients as bridge to lung transplantation. Am J Respir Crit Care Med. 2012;185(7):763–8.CrossRefGoogle Scholar
  38. 38.
    Mohite PN, et al. Extracorporeal life support in “awake” patients as a bridge to lung transplant. Thorac Cardiovasc Surg. 2015;63:699–705.CrossRefGoogle Scholar
  39. 39.
    Tsao NW, et al. Extracorporeal membrane oxygenation-assisted primary percutaneous coronary intervention may improve survival of patients with acute myocardial infarction complicated by profound cardiogenic shock. J Crit Care. 2012;27(5):530 e1–11.CrossRefGoogle Scholar
  40. 40.
    Sheu JJ, et al. Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock. Crit Care Med. 2010;38(9):1810–7.CrossRefGoogle Scholar
  41. 41.
    Asaumi Y, et al. Favourable clinical outcome in patients with cardiogenic shock due to fulminant myocarditis supported by percutaneous extracorporeal membrane oxygenation. Eur Heart J. 2005;26(20):2185–92.CrossRefGoogle Scholar
  42. 42.
    Diddle JW, et al. Extracorporeal membrane oxygenation for the support of adults with acute myocarditis. Crit Care Med. 2015;43(5):1016–25.CrossRefGoogle Scholar
  43. 43.
    Brechot N, et al. Venoarterial extracorporeal membrane oxygenation support for refractory cardiovascular dysfunction during severe bacterial septic shock. Crit Care Med. 2013;41(7):1616–26.CrossRefGoogle Scholar
  44. 44.
    Huang CT, et al. Extracorporeal membrane oxygenation resuscitation in adult patients with refractory septic shock. J Thorac Cardiovasc Surg. 2013;146(5):1041–6.CrossRefGoogle Scholar
  45. 45.
    Maggio P, et al. Extracorporeal life support for massive pulmonary embolism. J Trauma. 2007;62(3):570–6.CrossRefGoogle Scholar
  46. 46.
    Pokersnik JA, et al. Have changes in ECMO technology impacted outcomes in adult patients developing postcardiotomy cardiogenic shock? J Card Surg. 2012;27(2):246–52.CrossRefGoogle Scholar
  47. 47.
    Khan MS, et al. Is mechanically bridging patients with a failing cardiac graft to retransplantation an effective therapy? Analysis of the United Network of Organ Sharing database. J Heart Lung Transplant. 2012;31(11):1192–8.CrossRefGoogle Scholar
  48. 48.
    Chen YS, et al. Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet. 2008;372(9638):554–61.CrossRefGoogle Scholar
  49. 49.
    Shin TG, et al. Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: a comparison with conventional cardiopulmonary resuscitation. Crit Care Med. 2011;39(1):1–7.CrossRefGoogle Scholar
  50. 50.
    Shin TG, et al. Two-year survival and neurological outcome of in-hospital cardiac arrest patients rescued by extracorporeal cardiopulmonary resuscitation. Int J Cardiol. 2013;168(4):3424–30.CrossRefGoogle Scholar
  51. 51.
    Halter J, et al. Evidence of systemic cytokine release in patients undergoing cardiopulmonary bypass. J Extra Corpor Technol. 2005;37(3):272–7.PubMedPubMedCentralGoogle Scholar
  52. 52.
    Underwood MJ, et al. Changes in “inflammatory” mediators and total body water during extra-corporeal membrane oxygenation (ECMO). A preliminary study. Int J Artif Organs. 1995;18(10):627–32.CrossRefGoogle Scholar
  53. 53.
    Noerr B. ECMO and pharmacotherapy. Neonatal Netw. 1996;15(6):23–31.PubMedGoogle Scholar
  54. 54.
    Dagan O, et al. Preliminary studies of the effects of extracorporeal membrane oxygenator on the disposition of common pediatric drugs. Ther Drug Monit. 1993;15(4):263–6.CrossRefGoogle Scholar
  55. 55.
    Toomasian JM, Bartlett RH. Hemolysis and ECMO pumps in the 21st century. Perfusion. 2011;26(1):5–6.CrossRefGoogle Scholar
  56. 56.
    Masiakos PT, et al. Extracorporeal membrane oxygenation for nonneonatal acute respiratory failure. Arch Surg. 1999;134(4):375–9; discussion 379–80.CrossRefGoogle Scholar
  57. 57.
    Mehta U, et al. Extracorporeal membrane oxygenation for cardiac support in pediatric patients. Am Surg. 2000;66(9):879–86.PubMedGoogle Scholar
  58. 58.
    Rosenberg AA, et al. Prolonged duration ECMO for ARDS: futility, native lung recovery, or transplantation? ASAIO J. 2013;59(6):642–50.CrossRefGoogle Scholar
  59. 59.
    Oliver WC. Anticoagulation and coagulation management for ECMO. Semin Cardiothorac Vasc Anesth. 2009;13(3):154–75.CrossRefGoogle Scholar
  60. 60.
    Combes A, et al. Position paper for the organization of extracorporeal membrane oxygenation programs for acute respiratory failure in adult patients. Am J Respir Crit Care Med. 2014;190(5):488–96.CrossRefGoogle Scholar
  61. 61.
    Barbaro RP, et al. Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the extracorporeal life support organization registry. Am J Respir Crit Care Med. 2015;191(8):894–901.CrossRefGoogle Scholar
  62. 62.
    Paden ML, et al. Extracorporeal life support organization registry report 2012. ASAIO J. 2013;59(3):202–10.CrossRefGoogle Scholar
  63. 63.
    Schmidt M, et al. Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The respiratory extracorporeal membrane oxygenation survival prediction (RESP) score. Am J Respir Crit Care Med. 2014;189(11):1374–82.CrossRefGoogle Scholar
  64. 64.
    Cheng R, et al. Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Ann Thorac Surg. 2014;97(2):610–6.CrossRefGoogle Scholar
  65. 65.
    Murray JF, et al. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis. 1988;138(3):720–3.CrossRefGoogle Scholar
  66. 66.
    Steiner CK, et al. Predictors of acquiring a nosocomial bloodstream infection on extracorporeal membrane oxygenation. J Pediatr Surg. 2001;36(3):487–92.CrossRefGoogle Scholar
  67. 67.
    Elerian LF, et al. Usefulness of surveillance cultures in neonatal extracorporeal membrane oxygenation. ASAIO J. 2001;47(3):220–3.CrossRefGoogle Scholar
  68. 68.
    Rao AS, et al. A novel percutaneous solution to limb ischemia due to arterial occlusion from a femoral artery ECMO cannula. J Endovasc Ther. 2010;17(1):51–4.CrossRefGoogle Scholar
  69. 69.
    Ijsselstijn H, van Heijst AF. Long-term outcome of children treated with neonatal extracorporeal membrane oxygenation: increasing problems with increasing age. Semin Perinatol. 2014;38(2):114–21.CrossRefGoogle Scholar
  70. 70.
    Linden VB, et al. ECMO in ARDS: a long-term follow-up study regarding pulmonary morphology and function and health-related quality of life. Acta Anaesthesiol Scand. 2009;53(4):489–95.CrossRefGoogle Scholar
  71. 71.
    Schmidt M, et al. The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Intensive Care Med. 2013;39(10):1704–13.CrossRefGoogle Scholar
  72. 72.
    Gravel MT, et al. Kidney transplantation from organ donors following cardiopulmonary death using extracorporeal membrane oxygenation support. Ann Transplant. 2004;9(1):57–8.PubMedGoogle Scholar
  73. 73.
    Ingemansson R, et al. Clinical transplantation of initially rejected donor lungs after reconditioning ex vivo. Ann Thorac Surg. 2009;87(1):255–60.CrossRefGoogle Scholar
  74. 74.
    Posluszny J, Rycus PT, Bartlett RH, Engoren M, Haft JW, Lynch WR, Park PK, Raghavendran K, Napolitano L.Outcome of Adult Respiratory Failure Patients Receiving Prolonged (≥14 Days) ECMO.Ann Surg. 2016 Mar;263(3):573-81. doi:  10.1097/SLA.0000000000001176.CrossRefGoogle Scholar

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Authors and Affiliations

  1. 1.Department of SurgeryUniversity of Michigan Health SystemAnn ArborUSA
  2. 2.Division of Acute Care Surgery, Department of SurgeryUniversity of Health SystemAnn ArborUSA

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