Over the past few years, there have been steady advancements in the field of pediatric ECMO [12]. VV-ECMO provides only support for gas exchange with blood returning to the central venous circulation with no direct contribution to the systemic arterial circulation [11]. ECMO itself does not heal or treat the underlying condition(s), but it provides cardiac and/or respiratory support to allow the pathophysiology to resolve without toxic ventilation and/or inotropic support [12].

In the past, pulmonary parenchymal disease states constituted the main indication for respiratory ECMO, but nowadays it has been increasingly used to support children with severe respiratory failure from other etiologies, such as upper or lower airway obstructions, foreign body aspiration and hyperviscosity syndromes [12]. In children with respiratory failure, ECMO is generally used as a rescue therapy and there is a tendency to provide earlier and earlier ECMO support, even in minimally sedated, spontaneously breathing patients [6,12].

In the absence of significant hemodynamic instability, VV-ECMO is usually sufficient to augment gas exchanges, allowing ventilator settings to be progressively weaned and, thus, potentially reducing ventilator-induced lung injury and oxygen toxicity [12]. VV-ECMO has plausible advantages in pediatric patients with good cardiac function, namely preservation of more physiological hemodynamics, better neurological outcome, easier mobilization and a lower complication rate, once it can be established without cannulation of any artery [12,16,18]. The use of ECMO for pediatric asthma has limited retrospective data that suggest excellent survival with relatively shorter time spent on ECMO, but offers little insight concerning potential morbidity or mortality benefit [7,8,11]. Although few evidence exists regarding the ideal mode of ventilation while receiving ECMO, a lung rest approach seems to avoid any further exacerbation of ventilator-induced lung injury and subsequent further inflammation [11,13].

Pediatric patients on ECMO have traditionally been maintained deeply sedated and, sometimes, paralyzed [12]. Excessive pharmacologic sedation and unnecessary paralysis have been increasingly associated with possible circulatory complications, showing also a strong correlation with delirium [2,12]. They have also been considered important risk factors for increased morbidity and mortality in critically ill populations, whichsupports the recent paradigm shift within the PICU community toward less sedation and earlier mobilization [2, 12]. Besides de-escalation of pharmacologic sedation in the absence of noxious pharyngeal stimulation from the end tracheal tube, extubation during ECMO presents a tantalizing goal with several other benefits, including avoidance of ongoing ventilator induced lung and airway trauma, resolution of air leak, facilitation of airway clearance (through spontaneous breathing and cough), mitigation of neuromuscular deconditioning and improving family bond [11,13,17].

Nevertheless, and despite the growing interest, awake ECMO can be associated with severe complications due to the potentially higher risk of cannula dislocation resulting from active movements of the conscious patient [2,6,16]. Although this concern of dislodgement is theoretically higher in children, there are emerging studies demonstrating that awake ECMO can be safely performed in this population [12,16]. Thus, good fixation of the cannula is of utmost importance to allow mobilization and the practice of awake ECMO requires significant team preparation and mindful balance of potential risks andbenefits on an individualized basis [13,16,19]. The authors present the first successful trial of pediatric awake ECMO in their PICU. This report corroborates the actual evidence that, in selected patients, extubation and appropriately decreased sedation is safe and does not itself compromise the effectiveness of extracorporeal life support [13].

Despite the increasing list of successful case reports, careful patient selection remains the most important single factor to be considered by ECMO providers [12,20]. In fact, our patient revealed an exquisite level of collaboration for her age, what decisively contributed not onlyto the success of the treatment, but also to the absence of complications with both the cannulas and the circuit of ECMO. Even though our patient’s recovery was fast, the concept of awake ECMO can be applied over longer periodsand, for now, its benefits are believed to fairly exceed the risks [2,19,21,22]. Further reports and multicenter research are essential to refine the management of children supported on ECMO [2,12,23]. In the near future, it is likely that awake ECMO and early mobilization will become the new standard of care for pediatric patients with respiratory failure [2,13,24]. But for now, it is in our hands not only to accurately predict which patients can be saved by ECMO, but also to minimize as much as possible the inherent morbidity, allowing these children, when appropriate, to be awake, extubated and even ambulatory [12,18].

Acknowledgements: There is nothing worth mentioning in this section.