Extubation during extracorporeal membrane oxygenation in adults: An international qualitative study on experts' opinions

Background: Extracorporeal membrane oxygenation in adults (adult-ECMO), a modification of cardiopulmonary bypass is increasingly used. Liberation from mechanical ventilation, or extubation, during adult-ECMO remains a challenge. Objectives: This study aimed to understand expert perceptions of the reasonableness of extubation during adult-ECMO and the usefulness of an extubation clinical practice guideline (ECPG). Methods: Homogeneous purposive sampling, focus groups, and interviews with a discussion guide, and direct content, thematic analysis were used. Results: Fourteen volunteers participated with different educational levels (79% Doctor of Medicine, 14% Registered Nurse, 7% Nurse Practitioner), from high-volume ECMO centers of various annual ECMO runs (50% 30-49 ECMO/year, 36% 50-99 ECMO/year, 14% >100 ECMO/year) worldwide (64% North America, 21% South America, 7% Europe, 7% Asia). Seven themes were identified: paucity of evidence, mindsets towards using an ECPG, barriers, criteria and benefits of extubation, culture towards extubation and vision of the future. Participants recommended aiming for extubation based on patient selection, and a standardized extubation approach with an ECPG or team decision-making. Conclusion: Application of adult-ECMO is expanding, during which extubation remains difficult. Experts recommend two methods of a standardized extubation approach. (C) 2021 Elsevier Inc. All rights reserved.