• Referral to a tertiary respiratory centre should be considered in the following situations:
    • Severe hypoxaemia (for example, PaO2/FiO2 <13.3kPa)
    • Severe hypercapnic acidosis (for example, pH <7.20)
    • Inability to achieve lung-protective tidal volumes and pressures (tidal volume < 6ml/kg predicted body weight, plateau pressure <30cmH2O)
    • Failure to improve with rescue therapies such as prone positioning
    • Significant air leak/bronchopleural fistula
  • The most widely used indications for ECMO are those reported in the CESAR study
  • The NHS specialise service clarified indications and contraindications during their commissioning service:
    • Age ≥16 years
    • Potentially reversible severe acute respiratory failure
    • No limitation to on-going life-sustaining treatment
    • Murray score ≥3.0 (consider referral is ≥2.5 and rapid clinical deterioration) OR
    • Uncompensated hypercapnia with pH <7.20
    • Age >65 years
    • Intracranial bleed (current or recent)
    • Other contraindications to heparinisation
    • High pressure (peak inspiratory pressure >30 H2O or high FiO2 (>0.8) ventilation for more than seven days