Mechanical ventilation before and during veno-venous extracorporeal membrane oxygenation

INTRODUCTION: Veno-Venous Extracorporeal Membrane Oxygenation (VV ECMO) has revolutionized severe acute respiratory distress syndrome (ARDS) management by decoupling gas exchange from native lung function, minimizing ventilator-induced lung injury (VILI). However, optimizing mechanical ventilation before and during extracorporeal support remains unstandardized. AREAS COVERED: Pre-ECMO management heavily influences survival, requiring clinicians to balance the cumulative 'dose' of injurious ventilation against cannulation timing. On ECMO, practice remains divided between an 'open lung approach,' using higher PEEP to prevent derecruitment, and a 'closed lung approach,' prioritizing low PEEP and near-complete lung rest. Transitioning to spontaneous breathing introduces a trade-off between preventing diaphragmatic atrophy and risking patient self-inflicted lung injury (P-SILI) from excessive transpulmonary pressure swings. This review synthesizes evidence, addresses key controversies on cardiopulmonary interplay and weaning, and outlines strategies for personalizing ventilation during VV ECMO. We searched in the Medline database from inception to August 2026 to identify relevant literature on the management of veno-venous ECMO in the pre-ECMO phase, on-support, and during the weaning phases from VV ECMO. EXPERT OPINION: VV ECMO enables lung-protective ventilation and 'buys time' for native lung recovery, but optimal management across the pre-ECMO, on-support, and weaning phases remains non-standardized and requires individualized, physiology-driven strategies rather than fixed protocols.