Lung Derecruitment During Venovenous Extracorporeal Membrane Oxygenation: A Physiology-Based Clinical Framework

Venovenous extracorporeal membrane oxygenation (VV ECMO) has transformed the management of severe acute respiratory distress syndrome (ARDS) by enabling ultra-lung-protective ventilation, thereby reducing ventilator-induced lung injury. However, this strategy creates a therapeutic paradox: the same reductions in tidal volume and transpulmonary pressure that protect the injured lung also promote progressive alveolar derecruitment and atelectasis, which may impede lung recovery and become an important barrier to liberation from extracorporeal support. Despite the frequency with which this problem is encountered, there is little guidance on the prevention, recognition, and management of lung derecruitment during prolonged VV ECMO support. Current evidence supporting strategies to prevent or reverse derecruitment remains limited and is largely derived from physiologic studies, observational cohorts, and extrapolation from the broader ARDS literature. Conventional ventilator optimization, individualized positive end-expiratory pressure (PEEP), and driving-pressure minimization remain the foundation of management. Adjunctive therapies—including electrical impedance tomography-guided PEEP titration, prone positioning, spontaneous breathing, airway pressure release ventilation, verticalization, and emerging techniques such as negative pressure ventilation—have shown varying degrees of physiologic benefit, although high-quality evidence demonstrating improved patient-centered outcomes remains limited. In this evidence-based clinical review, we summarize the mechanisms underlying lung derecruitment during VV ECMO, critically evaluate the available evidence supporting current recruitment strategies, and propose a practical framework to prevent and manage persistent lung derecruitment during prolonged VV ECMO support. Rather than advocating a single recruitment strategy, we propose an individualized approach that prioritizes lung protection while tailoring recruitment strategies to lung recruitability, respiratory mechanics, and the strength of the available evidence.