Awake Extracorporeal Membrane Oxygenation Research Articles

Spontaneous breathing in patients with severe acute respiratory distress syndrome receiving prolonged extracorporeal membrane oxygenation

BackgroundThe use of extracorporeal membrane oxygenation (ECMO) in awake, spontaneously breathing and non-intubated patients (awake ECMO) may be a novel therapeutic strategy for severe acute respiratory distress syndrome (ARDS) patients. The purpose of this study is to assess the feasibility and safety of awake ECMO in severe ARDS patients receiving prolonged ECMO (> 14 days).MethodsWe describe our experience with 12 consecutive severe ARDS patients (age, 39.1 ± 16.4 years) supported with awake ECMO to wait for native lung recovery during prolonged ECMO treatment from July 2013 to January 2018. Outcomes are reported including the hospital mortality, ECMO-related complications and physiological data on weaning from invasive ventilation.ResultsThe patients received median 26.0 (15.5, 64.8) days of total ECMO duration in the cohort. The longest ECMO support duration was 121 days. Awake ECMO and extubation was implemented after median 10.2(5.0, 42.9) days of ECMO. Awake ECMO was not associated with increased morbidity. The total invasive ventilation duration, lengths of stay in the ICU and hospital in the cohort were 14.0(12.0, 37.3) days, 33.0(22.3, 56.5) days and 46.5(27.3, 84.8) days, respectively. The hospital mortality rate was 33.3% (4/12) in the cohort. Survivors had more stable respiratory rate and heart rate after extubation when compared to the non-survivors.ConclusionsWith carefully selected patients, awake ECMO is a feasible and safe strategy for severe pulmonary ARDS patients receiving prolonged ECMO support to wait for native lung recovery.

TCT-818 Clinical Outcomes of Awake Extracorporeal Membrane Oxygenation as Bridge to Heart Transplantation

TCT-818 Clinical Outcomes of Awake Extracorporeal Membrane Oxygenation as Bridge to Heart Transplantation

Contemporary Outcomes of Extracorporeal Membrane Oxygenation Used as Bridge to Lung Transplantation

Extracorporeal membrane oxygenation (ECMO), when used as bridge to lung transplantation, (BTT) identifies high-risk candidates. Recent advances in cannula design and patient selection fosters "awake ambulatory ECMO" as a viable option for critically ill candidates in an attempt to retard deconditioning while awaiting allografts. From 2012 to 2015, 30 patients underwent ECMO as BTT. Candidacy for ECMO was determined before listing for transplant. A dual-lumen single cannula was used first in 13 of 30 patients (43%). Of the remaining 30 patients, 6 (20%) were supported with venoarterial ECMO and 11 (37%) with venovenous ECMO, with double-site cannulation in 11 (37%), and 6 of 11 converted to a dual-lumen single cannula. All ECMO patients were managed in a dedicated heart/lung failure intensive care unit, and early aggressive physical therapy, ambulation, and spontaneous breathing trials were emphasized. BTT was successful in 26 patients (87%). In the 19 patients with dual-lumen single cannula, 5 (26%) were successfully ambulated, and 6 (32%) achieved spontaneous ventilation. Median (25th, 75th percentile) lengths of stay in the intensive care unit and hospital were 33 days (20, 46 days) and 56 days (28, 78 days), respectively, and were 20 and 31 days, respectively, in patients successfully ambulated (intensive care unit: p= 0.5; hospital: p= 0.4). Among all patients who received a transplant, 30-day, 1-year, and 3-year survival were 92%, 85%, and 80%, respectively. Among patients undergoing primary transplants, 3-year survival was 91%. ECMO as BTT has led to encouraging perioperative outcomes and early survival. Careful patient selection and early use of ECMO seems to allow for preservation of vitality while these critically ill candidates await donor organs, which may improve outcomes.

Mid-term results of bilateral lung transplant with postoperatively extended intraoperative extracorporeal membrane oxygenation for severe pulmonary hypertension†

In severe pulmonary hypertension, diastolic dysfunction of the left ventricle causes significant morbidity and mortality after lung transplantation, which may be successfully reversed using a protocol based on perioperative veno-arterial extracorporeal membrane oxygenation (ECMO) and early extubation. Here, we present echocardiographic data and mid-term outcomes. The records of lung transplanted patients at our institution between May 2010 and January 2016 were retrospectively reviewed. Echocardiography data were collected preoperatively, at discharge, 3 and 12 months after transplantation. During the study period, 717 patients underwent lung transplantation at our institution, 38 (5%) patients being transplanted for severe pulmonary hypertension. All patients underwent bilateral lung transplantation on veno-arterial ECMO cannulated in the groin, through a sternum sparing thoracotomy in 36 (95%) patients. Extubation was performed early, after a median of 2 days, and awake ECMO was extended for at least 5 days after transplantation. The survival at 3 months, 1 year and 5 years was not different in comparison to patients transplanted for other underlying diseases ( P = 0.45). At 1 year, tricuspid valve regurgitation had disappeared in all patients. The median of the left ventricular end-diastolic dimension improved from 40 (32-44) mm preoperatively to 45 (44-47) mm at 12 months after lung transplantation ( P < 0.05). The median of the proximal right ventricular outflow diameter decreased to 25 (23-27) mm after 12 months, compared to 48 (43-51) mm preoperatively ( P < 0.05). The routine application of a prophylactic postoperative veno-arterial ECMO protocol in patients with severe pulmonary hypertension undergoing lung transplantation decreases postoperative mortality and favours achievement of normal cardiac function after 1 year.

Awake Extracorporeal Membrane Oxygenation as Bridge to Lung Transplantation: A 9-Year Experience

Extracorporeal membrane oxygenation (ECMO) is used as a bridge to lung transplantation, but characteristics that influence its success are poorly understood. This large, single-center experience evaluated the implementation and outcomes of ECMO in this setting. Data were collected for patients at our institution (New York-Presbyterian Hospital/Columbia University Medical Center in New York) who received ECMO as a bridge to lung transplantation from January 1, 2007 through July 10, 2016. Data were analyzed for demographics, baseline characteristics, survival, and ECMO configuration. Seventy-two patients received ECMO as a bridge to lung transplantation. Of the 72 patients, 40 (55.6%) underwent the transplantation procedure, 37 (92.5%) survived to discharge, and 21 (84.0%) survived for 2 years. Inotropy or vasopressor support (70% vs 93.8%; p= 0.011), Simplified Acute Physiology Score (26.8 vs 30.5; p= 0.048), and ambulation (80% vs 56.2%; p= 0.030) were significantly different between the patients who underwent lung transplantation and those who did not. Patients with cystic fibrosis were more likely to have a bridge to transplantation than patients with other lung diseases (47.5% vs 25%; p= 0.050). Daily participation in physical therapy was achieved in 50 patients (69.4%). This study demonstrated favorable survival in patients receiving ECMO as a bridge to lung transplantation and achieved high rates of physical therapy and avoidance of mechanical ventilation while ECMO was used in patients awaiting lung transplantation. With more than half of these patients successfully bridged to lung transplantation, we gained insight into the factors influencing patients' outcomes, including patient selection, timing of ECMO, and patient management.

Awake extracorporeal membrane oxygenation in a neonatal patient with respiratory failure

Background: Awake extracorporeal membrane oxygenation (ECMO) in conscious, extubated patients has been used successfully in adults and children, primarily as a bridge to lung or heart–lung transplantation and recovery from refractory cardiogenic shock. 1,2 However, this strategy has been reported only as an exceptional measure in neonatal patients. We present a case of neonatal respiratory failure where an infant was extubated while on ECMO and managed without invasive ventilation. Methods: The clinical details, laboratory investigations, management, and outcome of the patient were reviewed from the electronic health record. This single-patient case report was exempt from the IRB at our institution. The photograph was used with parental consent. Results: The patient was a 2950 g product of an uncomplicated term pregnancy, whose postnatal course was complicated by neonatal acute respiratory failure, pulmonary hypertension, and bilateral pneumothoraces. The infant was managed on veno-arterial (VA) ECMO. Des...

ECLS: Past, present, and future

Extracorporeal life support (ECLS) is the prototype example of translational research. It began in laboratory studies to design, test, and characterize devices for prolonged extracorporeal circulation in the 1960s. The first clinical cases of ECLS for heart and lung failure were in the 1970s. These cases were met with skepticism, but the results in neonatal respiratory failure were encouraging. In the early 1980s, two centers conducted randomized trials in neonates, which demonstrated much higher survival with ECLS, and the term extracorporeal membrane oxygenation (ECMO) was coined. By 1986, there were 18 neonatal ECMO centers and data on 700 cases. These centers formed a consortium (The Extracorporeal Life Support Organization: ELSO) to maintain the registry, define guidelines and techniques, provide education, and hold an annual meeting. In the 1990s, these centers expanded indications to older children with lung and heart failure. ECMO management for post-operative cardiac failure became standard in major pediatric heart centers. A multi-center randomized trial in the UK demonstrated a major survival advantage to ECMO in neonates. A few centers continued to evaluate and improve ECMO and extracorporeal CO2 removal (ECCOR) in adults with 50–60% survival in uncontrolled case series. At the ELSO meeting in 1999, a group met to plan a randomized trial in adult respiratory failure (ARDS). That study was carried out in the UK from 2002 to 2006 (the CESAR trial) using the same study design as the neonatal trial. The results were similar to the neonatal trial but adult intensivists were still skeptical, arguing that the single ECMO center in Leicester was just better at respiratory care than the other non-ECMO centers. During all this time, we used modified pumps, oxygenators, and other equipment designed for cardiac surgery. A new medical profession of “ECMO specialist” developed to manage the ECMO system and patient. The number of specialists determined the number of ECMO cases that could be treated. Around 2008, a few companies made major improvements in these devices and manufactured specific ECMO machines. These machines were much safer, simpler, and reliable than the early ECMO equipment, and patients could be managed for weeks, primarily by the bedside ICU nurse with support from the specialist. This new equipment came along at the same time as the H1N1 flu pandemic of 2008–2009. ECMO was remarkably successful in saving the sickest patients, and adult intensivists scrambled to learn the technology. This was born out by two matched-pairs trials. ECMO for ARDS (acute respiratory disease syndrome) grew rapidly in adult intensive care units (ICU). The use of awake ambulatory ECMO as a bridge to lung transplantation has been expanded to all ECMO patients, in fact, to all ICU patients.1 Currently, ECMO is used for severe heart and lung failure in all ages. Research is focused on improving anticoagulation and devices, defining indications, and new applications like septic shock, ECPR for cardiac arrest, and EDCD to salvage organs for transplantation. Laboratory research has continued as clinical practice proceeded, and it currently includes an artificial placenta for very premature infants and four versions of implantable, wearable lungs for chronic support.2

Extracorporeal Life Support as Bridge to Lung Retransplantation: A Multicenter Pooled Data Analysis

Extracorporeal life support (ECLS) as a bridge to lung retransplantation has been reported only anecdotally. Thus, we analyzed combined data from ourcenter with pooled data from published studies to identify selection criteria for this advanced therapy. Four patients at our center were bridged onECLS to lung retransplantation. Patient data were retrospectively retrieved from electronic records. The MEDLINE database was searched using the PubMed engine and yielded 13 relevant studies that included aminimum of 3 patients bridged to lung retransplantation, and four studies described detailed data on 17patients. Patient data from our center (n= 4) were pooled with data fromthe MEDLINE database (n= 17) and analyzed. Of 21 patients, 3 (14%) died on ECLS awaiting retransplantation, and 18 (86%) underwent retransplantation after a median of 37 months (range, 0 to 168 months) after primary transplantation. Type of ECLS wasextracorporeal carbon dioxide removal (ECCO2R) in4, venovenous extracorporeal membrane oxygenation (ECMO) in 7, venoarterial ECMO in 5, or was not mentioned in 2. The 90-day postoperative mortality was 28%. Overall 1-year survival was 48%. Patients bridged toretransplantation with ECCO2R/venovenous ECMO (p= 0.05) or on awake ECMO (p= 0.06) showed strong trends toward better survival in univariate analysis. Univariate and multivariate analysis identified a longer intertransplant interval as a statistically significant favorable prognostic factor. In a selected subgroup of patients (awake ECCO2R/venovenous ECMO support and intertransplant interval >2 years), 1-year survival reached 67%. Despite limited overall 1-year survival for patients bridged with ECLS to lung retransplantation, careful patient selection may yield an acceptable1-year survival of 67%.

Awake extracorporeal membrane oxygenation in patients with severe postoperative acute respiratory distress syndrome.

A clinical trial of extracorporeal membrane oxygenation (ECMO) as an alternative ventilator tool is being performed as a new indication for ECMO. The purpose of this study was to evaluate the feasibility of awake ECMO to increase the success rate of weaning patients from ECMO and ventilator care during treatment of postoperative severe acute respiratory distress syndrome (ARDS). We retrospectively analyzed the clinical reports of 10 patients who underwent awake ECMO due to postoperative ARDS between August 2012 and May 2015. We analyzed patient history, the partial arterial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio, and patient outcome. Seven patients (70%) were weaned from ECMO without difficulty; one patient failed to maintain awake ECMO, was re-intubated after 2 days of awake ECMO, and was re-tried on awake ECMO after 4 days of ventilator care. We weaned that patient from ECMO 2 days later. We weaned a total of eight patients (80%) from awake ECMO. The ECMO duration of surviving patients was 9.13±2.2 days (range, 6-12 days), and mean ventilator use duration was 6.8±4.7 days (range, 2-16 days). Two cases failed awake ECMO and died due to disease aggravation. Awake ECMO was a useful weaning strategy after severe postoperative ARDS, as it avoids long-duration use of mechanical ventilation. Additionally, it is possible for patients to breathe spontaneously, which might prevents respiratory muscle dystrophy.

Use of extracorporeal membrane oxygenation in an awake patient after a major trauma with an incidental finding of tuberculosis.

We report the use of extracorporeal membrane oxygenation (ECMO) in a trauma patient with an incidental finding of open tuberculosis (TB). Sedation was reduced during extracorporeal support and awake veno-venous ECMO was successfully performed. Subsequently, accidental cannula removal caused major blood loss which required the administration of cardiopulmonary resuscitation (CPR). Our case report demonstrates that the incidental finding of open TB is an important hint for differential diagnosis and that it should still be considered in high-income countries. In addition, awake ECMO appears to be a feasible therapeutic option in non-transplant patients, although the described case demonstrates that patient compliance and nursing care are important for therapeutic success to avoid complications, for example, inadvertent decannulation.

Physiotherapy for Patients on Awake Extracorporeal Membrane Oxygenation: A Systematic Review.

Extracorporeal membrane oxygenation (ECMO) is used as temporary life support in subjects with potentially reversible respiratory/cardiac failure. The principal purpose of this review was to assess the characteristics and potential advantages of physiotherapeutic interventions in subjects on awake ECMO support. Seven databases were interrogated: we searched titles, abstracts and keywords using the Medical Subject Headings terms 'extracorporeal membrane oxygenation' and 'rehabilitation' linked with the Boolean operator 'AND'. In total, 216 citations were retrieved. Nine citations satisfied our inclusion criteria and were subjected to full-text analysis. The numbers of patients enrolled in the included studies (most of which were case series) were low (n = 52). We found no prospective studies or randomized controlled trials. Overall, subjects on awake ECMO usually received a combination of passive and active physiotherapy, and most achieved an acceptable degree of autonomy after treatment. Emerging research in the field affords preliminary evidence supporting the safety of early mobilization and ambulation in patients on awake veno-venous ECMO support. Copyright © 2015 John Wiley & Sons, Ltd.

Extracorporeal Life Support in "Awake" Patients as a Bridge to Lung Transplant.

Traditionally, patients on extracorporeal membrane oxygenation (ECMO) are sedated and mechanically ventilated, which increases risk of complications related to immobility and mechanical ventilation. The purpose of this study was to assess the feasibility and highlight the benefits of a bridge to lung transplant (LTx) using "awake ECMO" support. The peripheral venovenous or venoarterial ECMO was implanted at a bedside. A retrospective study of patients undergoing LTx between January 2007 and March 2013 was performed. Outcomes in patients supported on ECMO as a bridge to LTx and kept "awake" (Group 1) were compared with the rest of the LTx patients (Group 2). In this period, 249 LTx were performed and in them 7 patients were bridged to LTx using "awake ECMO" strategy. Two patients were awake at ECMO implantation and throughout the therapy, and two patients were on ventilator support at the time of ECMO implantation who were extubated later and maintained awake until LTx. The remaining three patients were awake for some time during the ECMO. There was no statistically significant difference in most donor characteristics and recipient baseline characteristics as well as post-LTx parameters between the two groups. One-year survival estimate was not different between the groups: Group 1, 85.7% vs. Group 2, 86.3% (log rank p = 0.99). In end-stage lung disease, the ECMO can be commenced in "awake" patients and patients can be awakened on ECMO. The "awake ECMO" strategy may avoid complications related to mechanical ventilation, sedation, and immobilization and provide comparable outcomes in the high-risk LTx patients.

Lung Transplantation for Severe Pulmonary Hypertension—Awake Extracorporeal Membrane Oxygenation for Postoperative Left Ventricular Remodelling

Bilateral lung transplantation (BLTx) is an established treatment for end-stage pulmonary hypertension (PH). Ventilator weaning failure and death are more common as in BLTx for other indications. We hypothesized that left ventricular (LV) dysfunction is the main cause of early postoperative morbidity or mortality and investigated a weaning strategy using awake venoarterial extracorporeal membrane oxygenation (ECMO). In 23 BLTx for severe PH, ECMO used during BLTx was continued for a minimum of 5 days (BLTx-ECMO group). Echocardiography, left atrial (LA) and Swan-Ganz catheters were used for monitoring. Early extubation after transplantation was attempted under continued ECMO. Preoperatively, all patients had severely reduced cardiac index (mean, 2.1 L/min/m2). On postoperative day 2, reduction of ECMO flow resulted in increasing LA and decreasing systemic blood pressures. On the day of ECMO explantation (median, postoperative day 8), LV diameter had increased; LA and blood pressures remained stable. Survival rates at 3 and 12 months were 100% and 96%, respectively. Data were compared to two historic control groups of BLTx without ECMO (BLTx ventilation) or combined heart-lung transplantation for severe PH. Early after BLTx for severe PH, the LV may be unable to handle normalized LV preload. This can be effectively bridged with awake venoarterial ECMO.

Awake extracorporeal membrane oxygenation bridging for pulmonary retransplantation provides comparable results to elective retransplantation

Lung retransplantation became an accepted treatment for bronchiolitis obliterans syndrome (BOS). However, the value of different bridging modalities for these patients is controversial. We analyzed outcomes of 39 patients listed for retransplantation between 2008 and 2012. Patients were divided in 3 groups: 23 patients without any bridge modality (elective, Group 1), 11 patients on ventilation and full sedation with or without extracorporeal membrane oxygenation (ECMO) support (sedated bridging, Group 2), and 5 patients awake on ECMO support (awake bridging, Group 3). Waiting list mortality was 13% in Group 1, 39% in Group 2, and 0% in Group 3. Perioperative mortality was 20% in Group 1, 29% in Group 2, and 0% in Group 3. Significant differences between Groups 1 and 2 were calculated for time on post-operative ventilation (17.4 vs 27.3 days, p = 0.022), intensive care unit stay (22.0 vs 32.9 days, p = 0.026), and hospital stay (34.7 vs 54.1 days, p = 0.013). However, there were no significant differences between Groups 1 and 3 for post-operative ventilation time (17.4 vs 13.4 days, p = 0.192), for intensive care unit stay (22.0 vs 26.4 days, p = 0.169), or for hospital stay (34.7 vs 34.8 days, p = 0.367). Survival rates at 90 days, 1 year, and 2 years were 80%, 70%, and 53% in Group 1; 71%, 43%, and 29% in Group 2; and 100%, 60%, and 60% in Group 3, respectively. Awake ECMO bridging for retransplantation provides comparable results to elective retransplantation.

Extracorporeal membrane oxygenation instead of invasive mechanical ventilation in patients with acute respiratory distress syndrome

Dear Editor, Invasive mechanical ventilation with or without additional extracorporeal membrane oxygenation (ECMO) support represents standard treatment for patients with acute respiratory distress syndrome (ARDS). An ‘‘awake ECMO’’ strategy in order to avoid intubation and mechanical ventilation has been implemented as a bridge to lung transplantation in patients with chronic lung disease [1, 2] but has been used only occasionally in patients with ARDS [3]. We conducted a single-center, uncontrolled pilot trial designed to assess the feasibility of veno-venous ECMO in awake, non-intubated, spontaneously breathing patients with ARDS (www.clinical.govNCT01669 863 ). Patients between 18 and 75 years old presenting with moderate or severe ARDS were eligible. The main exclusion criteria were severe bleeding disorders and uncontrolled sepsis with multi-organ failure involving at least two organ systems. The Institutional Review Board (IRB) of Hannover Medical School approved and supervised the study and all patients provided written informed consent prior to ECMO insertion. Six patients with severe ARDS were enrolled as planned; four of them were immunocompromised. Patient characteristics and outcome parameters are shown in Table 1. All patients suffered from severe ARDS with PaO2/FiO2 ratios at most 100 mmHg while receiving noninvasive ventilation. Gas exchange patterns improved immediately after ECMO insertion and noninvasive ventilation could be stopped within 1 h in two patients. Three patients (patients 1, 4, and 5) were successfully weaned from ECMO after 10, 5, and 7 days, respectively, and discharged from the ICU without needing invasive mechanical ventilation. Patient 2 was also successfully weaned from ECMO support but developed respiratory failure due to an iatrogenic pneumothorax 2 days later and required intubation as a result. A protracted ICU course ensued, complicated by ventilatorassociated pneumonia and sepsis. The patient was eventually discharged from the ICU after 50 days. Patient 3 improved rapidly on ECMO support, but became increasingly agitated and confused. On the 7th day on ECMO support, he intentionally removed his jugular cannula, resulting in emergency intubation and brief cardiopulmonary resuscitation. He subsequently died 10 days later from

Extracorporeal membrane oxygenation in a nonintubated patient with acute respiratory distress syndrome

To the Editors: Endotracheal intubation and mechanical ventilation are mainstays in the management of patients with acute respiratory distress syndrome (ARDS), but this treatment strategy exposes the patient to several risks and complications. A small number of ARDS patients can be treated with noninvasive ventilation and these patients have less ventilator-associated pneumonia and a lower mortality rate [1]. However, failure to improve oxygenation with noninvasive ventilation indicates the need for endotracheal intubation [1]. In patients with severe respiratory failure, extracorporeal membrane oxygenation (ECMO) is increasingly being used on top of mechanical ventilation to facilitate oxygenation and protective ventilation [2]. A novel concept is the use of ECMO in awake, spontaneously breathing patients to avoid the complications of invasive ventilation. So far, “awake ECMO” has been used predominantly in patients with end-stage lung disease as bridge to lung transplantation [3, 4]. The use of awake ECMO as …

Lungentransplantation

Since the early days of lung transplantation the demand for donor organs has outstripped donor organ availability. Consequently waiting times continue to increase with patients of highest priority often waiting several weeks or even months until a suitable donor organ becomes available resulting in considerable mortality on the waiting list. These issues have led to renewed interest in bridging strategies for patients with end-stage lung disease. The use of endotracheal intubation and mechanical ventilation (MV) has been viewed as a last resort as the majority of intubated patients fail to reach transplantation and those who do tend to have a poor postoperative outcome. New bridging strategies with awake extracorporeal membrane oxygenation (ECMO) seem to be hopeful alternatives in some patients. In the early intensive care unit (ICU) phase primary graft dysfunction, acute rejection, infections and surgical complications are common problems. Later, rejection, infection and sepsis, special airway complications and pulmonary bleeding may be reasons for ICU treatment.

Extracorporeal Membrane Oxygenation in Awake Patients as Bridge to Lung Transplantation

The use of extracorporeal membrane oxygenation (ECMO) in patients who are awake and spontaneously breathing may represent a novel bridging strategy toward lung transplantation (LuTx). To evaluate the outcomes of patients treated with the "awake ECMO" concept as bridge to transplantation. We performed a retrospective, single-center, intention-to-treat analysis of consecutive LuTx candidates with terminal respiratory or cardiopulmonary failure receiving awake ECMO support. The outcomes were compared with a historical control group of patients treated with conventional mechanical ventilation (MV group) as bridge to transplant. Twenty-six patients (58% female; median age, 44 yr; range, 23-62) were included in the awake ECMO group and 34 patients (59% female; median age, 36 yr; range, 18-59) in the MV group. The duration of ECMO support or MV, respectively, was comparable in both groups (awake ECMO: median, 9 d; range, 1-45. MV: median, 15 d; range, 1-71; P = 0.25). Six (23%) of 26 patients in the awake ECMO group and 10 (29%) of 34 patients in the MV group died before a donor organ was available (P = 0.20). Survival at 6 months after LuTx was 80% in the awake ECMO group versus 50% in the MV group (P = 0.02). Patients in the awake ECMO group required shorter postoperative MV (P = 0.04) and showed a trend toward a shorter postoperative hospital stay (P = 0.06). ECMO support in patients who are awake and nonintubated represents a promising bridging strategy, which should be further evaluated to determine its role in patients with end-stage lung disease awaiting LuTx.