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Published on: October 24, 2018
Does Extracorporeal Membrane Oxygenation Improve Survival in Pediatric Acute Respiratory Failure?
Ryan P Barbaro1,2, Yuejia Xu3, Santiago Borasino4
11 Department of Pediatrics and.
Insights
Extracorporeal membrane oxygenation (ECMO) did not improve survival or functional status in children with severe acute respiratory distress syndrome (ARDS). Further randomized trials are needed to confirm these findings for pediatric respiratory failure.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Physiology
- Extracorporeal Life Support
Background:
- Extracorporeal membrane oxygenation (ECMO) has been used for over 40 years to support gas exchange in children with severe respiratory failure.
- Despite its widespread use, robust efficacy studies comparing ECMO to conventional support are lacking.
Purpose of the Study:
- To compare mortality and functional outcomes in children with severe acute respiratory failure who received ECMO versus those who did not.
- To evaluate the efficacy of ECMO in pediatric patients with severe ARDS.
Main Methods:
- A cohort study design was employed, comparing ECMO-supported children with pair-matched non-ECMO controls from the RESTORE clinical trial.
- Individual case matching and propensity score matching were utilized to create comparable groups.
- Primary endpoint was in-hospital mortality; secondary outcomes included hospital-free and ventilator-free days, and functional status at discharge.
Main Results:
- Using individual case matching (60 pairs), in-hospital mortality at 90 days was 25% for both ECMO and non-ECMO groups (P > 0.99).
- Propensity score matching (61 pairs) showed similar mortality rates: 25% for ECMO vs. 30% for non-ECMO (P = 0.70).
- No significant differences were observed in secondary outcomes between the ECMO-supported and non-ECMO-supported children.
Conclusions:
- This study found no evidence that ECMO support leads to superior outcomes in children with severe ARDS compared to non-ECMO support.
- A definitive conclusion requires a rigorous, multisite randomized controlled trial to ascertain ECMO's true efficacy in this population.
Rationale:
Extracorporeal membrane oxygenation (ECMO) has supported gas exchange in children with severe respiratory failure for more than 40 years, without ECMO efficacy studies.
Objectives:
To compare the mortality and functional status of children with severe acute respiratory failure supported with and without ECMO.
Methods:
This cohort study compared ECMO-supported children to pair-matched non-ECMO-supported control subjects with severe acute respiratory distress syndrome (ARDS). Both individual case matching and propensity score matching were used. The study sample was selected from children enrolled in the cluster-randomized RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) clinical trial. Detailed demographic and daily physiologic data were used to match patients. The primary endpoint was in-hospital mortality. Secondary outcomes included hospital-free days, ventilator-free days, and change in functional status at hospital discharge.
Measurements And Main Results:
Of 2,449 children in the RESTORE trial, 879 (35.9%) non-ECMO-supported patients with severe ARDS were eligible to match to 61 (2.5%) ECMO-supported children. When individual case matching was used (60 matched pairs), the in-hospital mortality rate at 90 days was 25% (15 of 60) for both the ECMO-supported and non-ECMO-supported children (P > 0.99). With propensity score matching (61 matched pairs), the ECMO-supported in-hospital mortality rate was 15 of 61 (25%), and the non-ECMO-supported hospital mortality rate was 18 of 61 (30%) (P = 0.70). There was no difference between ECMO-supported and non-ECMO-supported patients in any secondary outcomes.
Conclusions:
In children with severe ARDS, our results do not demonstrate that ECMO-supported children have superior outcomes compared with non-ECMO-supported children. Definitive answers will require a rigorous multisite randomized controlled trial.
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