Role of Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome in Tropical Infections: A Comprehensive Review and Clinical Framework for Resource-limited Settings

Acute respiratory distress syndrome (ARDS) is a significant cause of critical disease in the tropics caused by infection with dengue, malaria, leptospirosis, scrub typhus, H1N1 influenza, and Nipah, which often result in dire hypoxemia and multiorgan dysfunction.These tropical pathogens are responsible in lower-and middle-income countries (LMICs), which contribute a significant percentage of ARDS admissions, and in many cases, this disease affects the younger age group and causes high mortality despite lung-protective ventilation.This is further deteriorated by limitations in monitoring, diagnosis delays, and limited resources of the intensive care unit (ICU).Studies have shown that prompt referral to extracorporeal membrane oxygenation (ECMO)-capable centers increases survival, but there is scant data on tropical infections.In LMICs, ECMO use is difficult due to extreme thrombocytopenia, coagulopathy, hemolysis, and shock, which characterize most tropical infections, necessitating patientspecific anticoagulation regimens, early intervention, and patient selection.Other obstacles are low ECMO capacity, excessiveness, shortage of skilled personnel, weaknesses of the supply chain, and ethical issues of resource distribution.Multiorgan dysfunction can be reinforced by incorporating ECMO with adjunct therapy, which includes continuous renal replacement therapy (CRRT) in cases of leptospirosis-related renal failure, plasmapheresis in severe cases of scrub typhus, and veno-arteriovenous (VAV) ECMO in cases of myocarditis.The review will synthesize disease-specific pathophysiology, clinical signatures, contraindications, and practical considerations of ECMO in tropical ARDS, and suggest a pragmatic, resource-sensitive decision model for the LMIC contextual setting.Enhancing regional ECMO networks, incorporating portable systems, and implementing tropical disease registries can help to increase access and better outcomes.Clinical significance: Severe ARDS secondary to tropical infections carries high mortality in LMICs due to delayed referral, coagulopathy, and limited access to advanced organ support.This review highlights disease-specific predictors, anticoagulation challenges, and a pragmatic ECMO decision framework to optimize survival while ensuring rational resource utilization in tropical critical care settings.