Weaning from venovenous extracorporeal membrane oxygenation for acute respiratory failure: challenges and opportunities

PURPOSE OF REVIEW: The process of weaning from venovenous extracorporeal membrane oxygenation (V-V ECMO) is a critical step in the recovery of patients with severe acute respiratory distress syndrome (ARDS), yet clinical practice is highly variable and lacks strong evidence-based guidance. This review summarizes the current understanding and emerging data on weaning from V-V ECMO while highlighting key areas for future research. RECENT FINDINGS: While several single-center studies have evaluated structured weaning protocols, no definitive multicenter trial with patient-centered outcomes has been completed. Recent work has highlighted physiologic predictors of successful weaning such as tidal volume, carbon dioxide clearance, and diaphragm function, as well as the challenges posed by ICU-acquired weakness, prolonged ECMO runs, and severe lung injury. Importantly, even patients requiring extended ECMO support can often be weaned successfully, and premature decisions about irreversibility should be avoided. SUMMARY: The optimal strategy for weaning V-V ECMO remains an area of clinical uncertainty. Protocolized approaches, careful physiologic monitoring, and patience may improve outcomes. Ongoing trials and future research will be critical in shaping evidence-based guidelines for liberation from ECMO support.