Awake Venovenous Extracorporeal Membrane Oxygenation in the Intensive Care Unit: Challenges and Emerging Concepts

Extracorporeal membrane oxygenation (ECMO) is an advanced treatment for severe respiratory failure. Implantation of ECMO before invasive ventilation or extubation during ECMO has been reported and is becoming increasingly popular. Avoidance of sedation and invasive ventilation during ECMO (commonly referred to as "awake ECMO") may have potential advantages, including a lower rate of delirium, shorter mechanical ventilation time, and the possibility of undergoing early rehabilitation and/or physiotherapy. However, awake ECMO is also associated with several risks, such as self-inflicted lung injury and cannula displacement or self-removal. Accordingly, invasive ventilation before ECMO, as well as weaning from ECMO before weaning from mechanical ventilation, remain the most common approaches. In this review, the authors describe indications, contraindications, advantages, disadvantages, and current evidence on the use of ECMO without invasive ventilation in patients with respiratory failure.