Use this decision tree if the patient being supported on VV ECMO is under consideration for weaning.

Prerequisites and considerations include:

Improvement in blood gases on unchanged or reduced ECMO support.
Improved lung compliance.
Radiologic improvement of the lungs.
Low to moderate ventilatory support that would allow for escalation if needed off ECMO.

Additional considerations before VV ECMO weaning include:

Achieving a fluid status target at the patient’s dry weight through conservative fluid administration ± diuretics or continuous renal replacement therapy (CRRT);
Hemodynamic stability;
No evidence of untreated active pulmonary infection;
Resolving multiorgan failure, if present;
Adjusting mechanical ventilation from ultra-lung protective settings to more conventional settings immediately before a weaning trial, e.g., tidal volume of 6–8 mL/kg, Pplat ≤ 28 cm H2O and driving pressure <15 cm H2O.

Please note: This is just one approach to VV ECMO weaning for adults. There are other approaches you can consider.