title: "Awake" extracorporeal membrane oxygenation (ECMO): pathophysiology, technical considerations, and clinical pioneering.
abstract: Venovenous extracorporeal membrane oxygenation (vv-ECMO) has been classically employed as a rescue therapy for patients with respiratory failure not treatable with conventional mechanical ventilation alone. In recent years, however, the timing of ECMO initiation has been readdressed and ECMO is often started earlier in the time course of respiratory failure. Furthermore, some centers are starting to use ECMO as a first line of treatment, i.e., as an alternative to invasive mechanical ventilation in awake, non-intubated, spontaneously breathing patients with respiratory failure ("awake" ECMO). There is a strong rationale for this type of respiratory support as it avoids several side effects related to sedation, intubation, and mechanical ventilation. However, the complexity of the patient-ECMO interactions, the difficulties related to respiratory monitoring, and the management of an awake patient on extracorporeal support together pose a major challenge for the intensive care unit staff. Here, we review the use of vv-ECMO in awake, spontaneously breathing patients with respiratory failure, highlighting the pros and cons of this approach, analyzing the pathophysiology of patient-ECMO interactions, detailing some of the technical aspects, and summarizing the initial clinical experience gained over the past years.
authors.affiliation: Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy. tom.langer@hotmail.it.
authors.forename: Thomas
authors.initials: T
authors.lastname: Langer
authors.affiliation: Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Santini
authors.affiliation: Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
authors.forename: Nicola
authors.initials: N
authors.lastname: Bottino
authors.affiliation: Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
authors.forename: Stefania
authors.initials: S
authors.lastname: Crotti
authors.affiliation: The Geneva Foundation, Tacoma, WA, USA.|Multi Organ Support and Preservation Task Area, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas, USA.
authors.forename: Andriy I
authors.initials: AI
authors.lastname: Batchinsky
authors.affiliation: Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.|Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Pesenti
authors.affiliation: Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.|Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.
authors.forename: Luciano
authors.initials: L
authors.lastname: Gattinoni
mesh_terms: D003243:Consciousness; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration; D012119:Respiration; D012121:Respiration, Artificial / Q000009:adverse effects / Q000379:methods; D012128:Respiratory Distress Syndrome / Q000503:physiopathology / Q000628:therapy; D012131:Respiratory Insufficiency / Q000503:physiopathology*; D055397:Ventilator-Induced Lung Injury / Q000503:physiopathology / Q000517:prevention & control