• Elena Spinelli, Eleonora Carlesso, and Tommaso Mauri.
• Dipartimento di Anestesia, Rianimazione ed Emergenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico.
• Curr Opin Crit Care. 2020 Feb 1; 26 (1): 66-72.

Purpose Of ReviewExtracorporeal support allows ultraprotective controlled and assisted ventilation, which can prevent lung and diaphragm injury. We focused on most recent findings in the application of extracorporeal support to achieve lung protection and diaphragm- protection, as well as on relevant monitoring.Recent FindingsA recent randomized trial comparing the efficacy of extracorporeal support as a rescue therapy to conventional protective mechanical ventilation was stopped for futility but post hoc analyses suggested that extracorporeal support is beneficial for patients with very severe acute respiratory distress syndrome. However, the optimal ventilation settings during extracorporeal support are still debated. It is conceivable that they should enable the highest amount of CO2 removal with lowest mechanical power.Extracorporeal CO2 removal can minimize acidosis and enable the use of ultra-protective lung ventilation strategies when hypoxemia is not a major issue. Moreover, it can protect lung and diaphragm function during assisted ventilation through control of the respiratory effort.Lung mechanics, gas exchange, diaphragm electrical activity, ultrasound, electrical impedance tomography could be integrated into clinical management to define lung and diaphragm protection and guide personalized ventilation settings.SummaryTechnological improvement and the latest evidence indicate that extracorporeal support may be an effective tool for lung and diaphragm protection.

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