Physiology-guided management of patients with severe hypoxemia ineligible for ECMO: a multidisciplinary lung rescue team approach

BACKGROUND: ARDS affects a significant proportion of ventilated ICU patients and carries high mortality, especially in cases of severe hypoxemia unresponsive to standard treatments and ineligible for extracorporeal membrane oxygenation (ECMO). In such situations, care often shifts to comfort measures due to limited data and structured guidance. To address this gap, Massachusetts General Hospital established the Lung Rescue Team (LRT), a multidisciplinary group using advanced physiological tools to provide individualized, real-time management beyond protocolized care. OBJECTIVE: To evaluate the feasibility and application of a complex, physiology-guided framework in patients with severe hypoxemia who had not responded to standard or advanced interventions and were ineligible for rescue therapies such as ECMO, population typically excluded from clinical trials and often regarded as beyond curative treatment. DESIGN: This single-center, retrospective observational study included adult patients in the intensive care unit (ICU) (n = 58) with severe hypoxemia not eligible for ECMO who were evaluated by the LRT at Massachusetts General Hospital between 2014 and 2025. Multimodal physiological assessments were performed which included electrical impedance tomography (EIT), esophageal manometry (EM), and transthoracic echocardiography (TTE). Interventions were categorized and clinical outcomes assessed. RESULTS: LRT consultation led to changes in respiratory management in 82.3% of patients who had already attend to receive maximal therapy, most commonly adjustments to PEEP based on EIT or transpulmonary pressure. The median ICU length of stay was 18.5 days (IQR 10.5–31.5). Survival was 48.3% at 90 days and 44.8% at 1 year. The leading cause of death was multiorgan failure (50%), followed by hypoxemia (25%) and unresponsive shock (25%). CONCLUSIONS: This study describes the experience of a physiology-guided, multidisciplinary LRT in patients with severe hypoxemia ineligible for ECMO, individuals often excluded from clinical trials and frequently considered beyond curative treatment. Survival in this cohort was far from negligible, highlighting the value of systematic re-evaluation rather than premature transition to palliation. Although causal inferences cannot be drawn from this retrospective, single-center analysis, the findings provide insight into an underreported population and generate hypotheses for future prospective studies.