For patients with refractory respiratory or cardiac failure, access to extracorporeal membrane oxygenation (ECMO) is frequently determined not by candidacy but rather by geography. Referral timing and interfacility coordination often determine whether extracorporeal support is instituted in time. Modern ECMO transport programs emerged as an innovative solution to centralize ECMO care and ensure that geography was not a barrier to obtaining advanced support.
Four major events accelerated the growth of dedicated ECMO transport programs around the world. The CESAR trial, the H1N1 influenza pandemic, the EOLIA trial, and the COVID-19 pandemic all pushed the field toward regionalization and early referral, and they ultimately transformed ECMO from a static therapy confined to tertiary care centers to an organized, mobile system of care.1
The CESAR trial was the first modern study to show that outcomes in severe ARDS improve when patients are referred to a specialized ECMO center. The intervention was not ECMO alone but management at a high-volume center.2 The trial highlighted a critical vulnerability: 6% of patients randomized to the ECMO group died before or during transport to the ECMO center. Had these patients been cannulated at the referring hospital and subsequently transferred to an ECMO center, it is possible that survival in the ECMO arm of the CESAR trial would have been higher. The CESAR trial plainly demonstrated that management at a high-volume center was associated with improved survival.
The 2009 H1N1 influenza pandemic marked an inflection point in the utilization of ECMO. Large numbers of previously healthy patients developed fulminant viral ARDS refractory to conventional mechanical ventilation (CMV). Tertiary centers that deployed mobile ECMO retrieval teams demonstrated that both bedside cannulation and transport—from ambulance to fixed-wing—could be performed safely with minimal complications. For example, across 15 ICUs in Australia and New Zealand, 49 of 68 patients (72%) who received ECMO required retrieval and interhospital transfer to the ECMO-providing site; of these, 38 (78%) were started on ECMO at the referring site and successfully transferred while receiving ECMO.3 The increased use of ECMO during the H1N1 pandemic led to high regional demand for extracorporeal support in the following years.4–5
In 2018, the EOLIA trial was published; although the primary end point (60-day mortality) was not statistically significant, the trial showed a large absolute mortality reduction favoring ECMO.6 Importantly, the trial established clear physiologic thresholds for ECMO consideration. This fortified a shared mental model across centers for when ECMO should be considered, helping referral centers identify candidates sooner and mobilize retrieval teams earlier. EOLIA provided the clinical framework to allow mobile teams developed in the wake of the H1N1 pandemic to become scalable.
The COVID-19 pandemic magnified the lessons that clinicians learned in 2009. ECMO case volumes exploded and referral pathways were standardized in many regions. During surge conditions in particular, coordinated allocation frameworks and interfacility retrieval capabilities became key components of critical care infrastructure.7 In Paris, for instance, they used six mobile ECMO teams shared across 17 ICUs in the city. Among 302 patients with COVID-19 ARDS, 55% were transferred following cannulation by a mobile ECMO team without any significant survival difference between patients who were cannulated at an outside hospital or a referral center.8
Several high-performing ECMO programs around the world have transported hundreds of patients with minimal complications. In the United States, both the University of Michigan and Columbia University have both had mature ECMO transport programs for decades with minimal transport-related complications.9–10 Internationally, the Karolinska Institute in Sweden conducted more than 900 interfacility transports with only two deaths during transport.9 Successful ECMO transport programs are united by a focus on personnel, the design of a centralized referral infrastructure, a standardized process from the initial call to the delivery of the patient to the referral center by the transport team, and a dedication to continual quality improvement (QI).11
The most effective programs also view the retrieval process as part of the continuum of critical care. Predeparture checklists are reviewed, flight crews are routinely drilled in circuit emergencies, and handoffs are standardized. Moreover, every transport mission is subject to intensive and structured QI with deliberate review undertaken of both clinical management and logistical performance.12
ECMO transport programs represent an evolution toward networked critical care—extending advanced critical care beyond fixed, tertiary care centers. The future of ECMO and any mechanical circulatory support hinges on the ability to construct robust regionalized networks of care that harness retrieval capability, tertiary care expertise, and equity of care, regardless of geography. Capable transport programs are a crucial element of any ECMO program that seeks to deliver advanced critical care support equitably.
References
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8. Lebreton G, Schmidt M, Ponnaiah M, et al. Extracorporeal membrane oxygenation network organisation and clinical outcomes during the COVID-19 pandemic in Greater Paris, France: a multicentre cohort study. Lancet Respir Med. 2021;9(8):851-862. doi:10.1016/S2213-2600(21)00096-8
9. Bryner B, Cooley E, Copenhaver W, et al. Two decades’ experience with interfacility transport on extracorporeal membrane oxygenation. Ann Thorac Surg. 2014;98(4):1363-1370. doi:10.1016/j.athoracsur.2014.06.025
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11. Labib A, August E, Agerstrand C, et al. Extracorporeal Life Support Organization guideline for transport and retrieval of adult and pediatric patients with ECMO support. ASAIO J. 2022;68(4):447-455. doi:10.1097/MAT.0000000000001653
12. Shouldice D, Felix A, Danielson K, et al. A simulation curriculum for ground and air ECMO transport. MedEdPORTAL. 2025;21:11508. doi:10.15766/mep_2374-8265.11508
