ARDS and refractory hypoxaemia

Refractory hypoxaemia and VV-ECMO

Reviewed Nov 2026·4 references
New· views rounded down, updated weekly

If P/F stays < 80 mmHg (or < 50 for 3 h) or pH < 7.25 with PaCO2 ≥ 60 despite optimised ventilation, proning and NMB, refer early to an ECMO centre (EOLIA criteria). Transfer before the patient is too unstable.

At the bedside

Timed steps
  1. 1

    Check the basics

    Optimise

    Vt 6 mL/kg, PEEP appropriate, proned, NMB, conservative fluids, treat infection, drain effusions, exclude pneumothorax and RV failure (echo).

  2. 2

    EOLIA

    Criteria

    P/F < 50 for > 3 h, or P/F < 80 for > 6 h, or pH < 7.25 with PaCO2 ≥ 60 mmHg for > 6 h (RR 35, Pplat ≤ 32).

  3. 3

    Early

    Refer

    Contact the ECMO centre early (within 7 days of ventilation preferred); discuss transfer or mobile ECMO retrieval.

  4. 4

    Consider

    Contraindications

    Ventilation > 7-10 days with high pressures, irreversible disease without transplant option, severe brain injury, contraindication to anticoagulation, very poor baseline. See module 14.

  5. 5

    Rescue

    While waiting

    Inhaled vasodilator, higher PEEP trial, sustained prone, accept SpO2 85-88%.

Red flag · call your senior now
Severe RV failure (acute cor pulmonale) on echo: reduce PEEP/PaCO2, prone, consider VV or VA ECMO.
Pitfall
Referring after 10 days of injurious ventilation.
Pearl
Calculate the Murray (LIS) score and RESP score when discussing referral.

References

  1. 1

    Combes A, Hajage D, Capellier G, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome (EOLIA). N Engl J Med. 2018;378(21):1965-1975

  2. 2

    Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR). Lancet. 2009;374(9698):1351-1363

  3. 3

    Qadir N, Sahetya S, Munshi L, et al. An update on management of adult patients with acute respiratory distress syndrome: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2024;209(1):24-36

  4. 4

    Grasselli G, Calfee CS, Camporota L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. 2023;49(7):727-759

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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.