How I monitor lung function during mechanical ventilation and veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome

PURPOSE OF REVIEW: Mechanical ventilation (MV) is central to the management of acute respiratory distress syndrome (ARDS). In refractory cases, veno-venous extracorporeal membrane oxygenation (VV-ECMO) can provide adequate gas exchange and facilitate protective ventilation. Effective management requires systematic monitoring of both the native lung (NL) and the membrane lung (ML). This review outlines an approach to monitoring ventilated patients, integrating physiological principles with clinical assessment. RECENT FINDINGS: Monitoring respiratory mechanics and inspiratory effort during controlled or assisted ventilation is essential to minimize the risk of ventilator-induced lung injury (VILI) and patient self-inflicted lung injury (P-SILI). New bedside methods have been validated, linking these measurements to both risk of injury and clinical outcomes. During VV-ECMO, accurate monitoring of ML function enables reduction in the intensity of MV and, subsequently, modulation of respiratory drive and effort. SUMMARY: Monitoring the respiratory system during MV and VV-ECMO in ARDS is essential to understand the interplay between the native and membrane lungs, both in controlled and assisted ventilation, where respiratory drive and effort are often unmeasured and overlooked. Careful selection and application of monitoring strategies therefore remain a cornerstone of safe management in these complex patients.