60: Mechanical ventilation in Children receiving VV ECMO with severe PARDS

Background: Significant advancements have been made in mechanical ventilation for ARDS. PALICC 2 recommends tidal volumes of 4–6 mL/kg, driving pressure below 15, and plateau pressure under 28 cmH2O. In cases of refractory hypoxemia, extracorporeal membrane oxygenation (ECMO) may be considered. Optimal ventilator strategies to minimize ventilator-induced lung injury (VILI) without prolonging ECMO due to lung collapse remain under investigation. Traditionally, a “lung-rest” strategy is used, and current ELSO guidelines advocate low rate, moderate PEEP (5–15 cmH2O), and low plateau pressures. Methods: Post hoc analysis was performed on prospectively collected data of children receiving ECMO for severe pediatric ARDS (PARDS) from January 2017 to November 2025. Ventilator settings, including PEEP and driving pressures during ECMO, were analyzed and compared between survivors and non-survivors. Results: During the study period, 28 children received ECMO for refractory hypoxemia due to severe PARDS. Median age was 54 months (IQR 37–120). Mean P/F ratio was 79 ± 23.59 and oxygenation index (OI) 32 ± 14.6 six hours prior to ECMO initiation. Mean PEEP during ECMO among survivors was 5 (5–6) versus 6 (5–7) in non-survivors (p=0.54). Mean driving pressure was 8 (5–11) in survivors and 9 (8–10) in non-survivors (p=0.5), showing no statistically significant differences. Conclusion: Maintaining lung aeration with moderate ventilator settings may promote lung healing and recovery in children with severe PARDS on ECMO. While traditional recommendations suggest PEEP around 10 cmH2O, our cohort required lower PEEP (5–6 cmH2O). Larger studies are needed to determine optimal pediatric ECMO ventilation strategies to ensure lung rest while preventing atelectasis.