Heparin-free veno-venous extracorporeal membrane oxygenation as a bridge therapy for airway interventions in malignant central airway obstruction

Rationale: Malignant central airway obstruction (MCAO) represents a life-threatening oncologic emergency that can lead to rapid respiratory decompensation and death. Traditional management with mechanical ventilation may be inadequate or risky when severe airway narrowing or complete obstruction exists. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) offers an alternative method of gas exchange that can support patients during high-risk airway interventions. This article presents 3 cases and reviews existing literature to evaluate the role of VV-ECMO as a bridge therapy for airway procedures in patients with MCAO. Patient concerns: All 3 patients presented with symptomatic airway stenosis secondary to malignant pulmonary or metastatic tumors, and conventional tracheal intubation failed to maintain adequate oxygenation and ventilation, necessitating urgent advanced respiratory support. Diagnoses: All 3 patients were diagnosed with respiratory failure secondary to bronchial obstruction caused by primary or secondary malignant lung tumors. Interventions: All patients were initiated on heparin-free VV-ECMO to establish stable extracorporeal gas exchange, followed by definitive interventional therapy via flexible bronchoscopy, including tumor debulking and/or airway stenting. Outcomes: Immediate improvement in oxygenation was achieved in all 3 patients following ECMO-supported intervention. Lessons: VV-ECMO serves as a viable bridge to definitive airway interventions in carefully selected patients with MCAO. Anticoagulation management requires careful balance, with a no-heparin protocol appearing safe for brief ECMO runs. Multidisciplinary collaboration is essential for optimal outcomes in these complex cases.