Tracheostomy During Extracorporeal Membrane Oxygenation in Adult ICU Patients: A Systematic Review

Background/Objectives: Extracorporeal membrane oxygenation (ECMO) is increasingly used in adult critical care, but tracheostomy during ECMO remains controversial because of bleeding risk, anticoagulation exposure, and variability in patient selection. This systematic review evaluated the safety, timing, and clinical outcomes of tracheostomy in adult patients receiving ECMO. Methods: A systematic search of PubMed/MEDLINE was supplemented by additional searches in the Cochrane Library/CENTRAL and Scopus to identify studies evaluating tracheostomy in adult ECMO patients. The review was conducted according to PRISMA 2020 guidelines. After database searching and screening, 13 observational studies were included in the qualitative synthesis. Results: Across 13 studies encompassing 1918 patients, tracheostomy during ECMO was feasible and was not associated with procedure-related mortality. Bleeding was the main procedural complication, with reported rates varying according to study design, ECMO configuration, timing of tracheostomy, anticoagulation management, and bleeding definitions. Tracheostomy performed during active ECMO support was generally associated with a higher burden of bleeding or minor procedure-related complications than tracheostomy performed after decannulation. Tracheostomy was performed using percutaneous, surgical, open, or hybrid techniques, although comparative evidence between approaches remained limited. Early tracheostomy was associated with shorter ECMO duration, shorter mechanical ventilation, or improved clinical outcomes in selected cohorts, but timing definitions and outcome measures were heterogeneous. Conclusions: Tracheostomy during ECMO may support airway management, sedation reduction, and ventilatory progression, particularly in prolonged ECMO courses, but it carries a relevant bleeding and transfusion burden. Timing, anticoagulation management, patient selection, ECMO configuration, and procedural technique are likely to influence the risk-benefit balance. Prospective studies are needed to standardize definitions, compare techniques, and clarify optimal timing strategies.