Extracorporeal Membrane Oxygenation: The Guardian Angel for the Severely Hypoxic and Its Judicious Use

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a useful modality when there is refractory hypoxemia not responding to conventional mechanical ventilation strategies or when conventional mechanical ventilation is not feasible.Extracorporeal membrane oxygenation, being a highly invasive modality with its own complications and expenses, it is imperative to rationalize its use.Lung protective ventilation, prone positioning, judicious use of neuromuscular blocking agents (NMBAs), driving pressure and transpulmonary pressure guided PEEP titration should be exploited first adequately before using VV-ECMO for any patient.Veno-venous extracorporeal membrane oxygenation is indicated only for those patients in whom these strategies fail or are not feasible.However, ECMO use has risen sharply in the past decade, immensely benefiting patients with severe cardiac/respiratory compromise, if used judiciously.This narrative review is aimed at highlighting the importance of adequate mechanical ventilation strategies and conservative fluid strategy before using VV-ECMO in any patient.We will also analyze the available evidence for the above-mentioned strategies along with the evidence for the use of VV-ECMO.