4, 7, 8, 53
ELSO 2021 VV guideline, which lists pH under 7.25 with PaCO2 at or above 60 mmHg as an indication; ANZ 2026 finds insufficient evidence to recommend ECMO routinely for hypercapnic failure in asthma or COPD.
The first GRADE-methodology ECMO guideline relevant to VV indications, developed to NHMRC 2016 standards. Weight it as a graded appraisal rather than expert synthesis. Diverges from ELSO on the hypercapnic indication. Its conditional recommendation against routine proning applies DURING ECMO and must not be confused with proning BEFORE ECMO, which ELSO treats as mandatory.
Conditional recommendation FOR VV ECMO in addition to standard care in severe hypoxaemic respiratory failure when conventional treatment fails, citing CESAR and EOLIA, with certainty of evidence limited by uncertainty about long-term outcomes. INSUFFICIENT EVIDENCE to recommend ECMO routinely in hypercapnic respiratory failure from severe asthma or COPD exacerbation, in the absence of randomised trials. Patients should have severe oxygenation failure despite optimised ventilation and typically fewer than seven days of mechanical ventilation before initiation. Conditional recommendation AGAINST routine proning during ECMO, citing limited evidence and cannula displacement risk. Recommends minimising tidal volume, driving pressure and mechanical power during support. Authors: Newman S, Burrell A, Buscher H, Chung D, Forrest P, Fraser J, French C, Hodgson C, Ling R, Litton E, MacLaren G, McKee A, Munn Z, Nguyen N, Pilowski J, Ramanathan K, Sackley M, Shekar K, Smith M, Stamp N, Wilkinson M, Wilson B, Nair P.
VV ECMO indications and management in adults, Australia and New Zealand