Awake extracorporeal membrane oxygenation in immunosuppressed patients with severe respiratory failure—a stretch too far?

The use of rescue extracorporeal membrane oxygenation (ECMO) in immunocompromised patients with acute respiratory distress syndrome (ARDS) is increasing with 5% to 31% of patients receiving ECMO (1,2) in recent studies. In the recently published ECMO to Rescue Lung Injury in Severe ARDS (EOLIA) trial, 22% of the recruits were identified as immunosuppressed and the sixty-day mortality of this sub-population was 56% and 78% in the ECMO and the control groups, respectively (3). Even though a post-hoc analysis of this small subgroup may not be definitive evidence for or against ECMO use in this population, it is important to note that “salvage” VV-ECMO (4) in the immunosuppressed is a futile exercise. However, this raises two important questions beyond crude mortality of this population: (I) might this population benefit from early VV-ECMO to liberate them from invasive mechanical ventilation (IMV) as soon as feasible? and (II) can IMV be avoided altogether in this cohort?