What is the age limit for ECMO?

September 21, 2025 •

5 min read

There is no single, specific age limit for ECMO (Extracorporeal Membrane Oxygenation); instead, a multidisciplinary team assesses a patient's entire health profile to determine candidacy. This complex decision factors in much more than a number, especially the reversibility of the underlying heart or lung condition.

Quick Summary

There is no official age cutoff for ECMO, but rather a holistic case-by-case assessment based on the patient's likelihood of recovery from a treatable condition. Key factors include the reversibility of the illness, the presence of comorbidities, and overall physiological reserve, which often decline with increasing age. Therefore, while age is a consideration, it is not an absolute barrier.

Key Points

No Absolute Limit: There is no specific, universal maximum age for ECMO; eligibility is determined on an individual basis by a clinical team.
Age and Outcome: While older age is linked to higher mortality rates, it is often tied to comorbidities rather than being an independent risk factor for poor outcomes.
Key Criteria: The most important factors for ECMO candidacy are the potential reversibility of the underlying heart or lung condition and the patient's overall health.
Neonatal Considerations: ECMO criteria for neonates historically included gestational age and weight, but improved technology has allowed some centers to consider even more premature infants.
Multidisciplinary Decision: The final decision to initiate ECMO involves a specialized team of medical professionals who weigh the therapy's significant benefits against its risks for the specific patient.
Goals of Care: Patient wishes and the potential for a meaningful recovery are central considerations in the eligibility process.

Understanding ECMO and Patient Selection

Extracorporeal Membrane Oxygenation (ECMO) is a form of advanced life support used for patients with life-threatening heart and/or lung failure. It functions as a temporary external heart-lung bypass machine, adding oxygen to the blood and removing carbon dioxide. Unlike the heart-lung machine used during surgery, ECMO can provide support for much longer periods, ranging from days to weeks or even months. It is a supportive measure, not a cure, designed to allow the patient's own organs time to rest and heal while the underlying disease is treated.

The Absence of a Universal Age Limit

Despite the common question, "What is the age limit for ECMO?," no specific, universally accepted maximum age exists. The Extracorporeal Life Support Organization (ELSO), a leading international authority on the therapy, intentionally refrains from setting a hard age cut-off. This reflects a crucial understanding in critical care: a patient's chronological age is often less important than their physiological age, overall health status, and the nature of their illness.

Instead of a rigid number, a comprehensive evaluation is performed by a specialized ECMO team. This team looks at numerous factors to determine if the potential benefits of this invasive and resource-intensive therapy outweigh the significant risks for an individual patient. For example, some institutional guidelines for ECPR (ECMO used during cardiac arrest) have historically used age as a criterion, but this is variable and based on institutional protocols rather than a universal standard.

Age and Outcomes: A Nuanced Perspective

While age is not a hard limit, it is undeniably a factor that influences the decision-making process because it is associated with overall health and resilience. Studies have shown a positive correlation between increasing age and higher mortality rates among ECMO patients. Some research, particularly concerning veno-venous (VV) ECMO for ARDS, notes that for each additional year of mean age, ICU mortality increased by a certain percentage.

However, this does not mean age is an independent risk factor. When researchers adjust for comorbidities and the severity of the illness, the impact of age is often attenuated. An elderly patient with few chronic conditions and good physiological reserve might be a better candidate than a younger patient with multiple severe comorbidities. The debate about using ECMO for elderly patients, especially those aged 65 and older, remains ongoing in the medical community.

Eligibility Criteria for Adults and Pediatrics

Beyond age, a constellation of factors determines a patient's eligibility:

Reversibility of Condition: The primary criterion is that the heart or lung failure must be potentially reversible. ECMO cannot save a patient from an unrecoverable disease.
Severity of Illness: The patient must be critically ill, with conventional treatments having failed. This is often quantified by scores like the Sequential Organ Failure Assessment (SOFA) or Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score.
Comorbidities: The presence of severe, irreversible organ damage (like end-stage liver or kidney disease) or disseminated malignancy can be a strong contraindication.
Neurological Status: Severe and irreversible brain injury is an absolute contraindication, as it removes the potential for a meaningful recovery.
Bleeding Risk: Patients on ECMO require powerful anticoagulants to prevent clots, which significantly increases bleeding risk. Uncontrollable bleeding or a contraindication to anticoagulation is a barrier.
Timing of Intervention: Prolonged high-pressure mechanical ventilation before ECMO initiation can negatively impact outcomes.
Vascular Access: Sufficient vascular access is necessary for cannulation.
Goals of Care: The patient's and family's wishes regarding aggressive life support are a vital part of the decision.

Special Considerations for Neonates and Children

For pediatric patients, especially neonates, specific criteria and risks have shaped guidelines. Historically, premature infants (e.g., <34 weeks gestational age or <2 kg birth weight) were largely excluded from ECMO due to a high risk of intracranial hemorrhage. However, advancements in technology and management techniques have led some high-volume centers to cautiously expand criteria for select, premature infants. For young children, the size of blood vessels can dictate where cannulas are placed. The key remains balancing the improved chances of survival against the significant risks and potential long-term neurodevelopmental outcomes.

Factors Influencing ECMO Eligibility: A Comparison


Factor	Impact on Eligibility
Age	A major consideration, with older age being associated with higher mortality, but not an absolute contraindication. Decision based on physiological, not chronological, age.
Reversibility of Condition	The most critical factor. The underlying illness (e.g., pneumonia, myocarditis) must be treatable to allow the heart or lungs to recover.
Comorbidities	Severe, irreversible, non-cardiac organ failures (liver, kidney) or advanced malignancy can preclude ECMO.
Neurological Status	Severe, irreversible brain injury is an absolute contraindication, as a good neurological outcome is unlikely.
Timing of Intervention	Delaying ECMO while a patient is on high-risk mechanical ventilation can reduce the chance of a positive outcome.
Bleeding Risk	Requiring continuous anticoagulation, a high risk of uncontrollable bleeding is a relative or absolute contraindication.

The Multidisciplinary Approach

The decision to initiate ECMO is never taken lightly or by a single individual. It involves a multidisciplinary team of experts, including intensive care physicians, surgeons, nurses, respiratory therapists, and perfusionists. The team collectively assesses the patient's clinical picture, using evidence from studies and institutional experience. They consider the patient's individual prognosis, quality of life, and the family's wishes to determine the best course of action. This comprehensive, team-based approach ensures that ECMO, a resource-intensive and high-risk therapy, is used for those with the highest chance of benefiting.

For more detailed information, the Extracorporeal Life Support Organization (ELSO) provides extensive guidelines and registry data on ECMO. You can learn more about their work and data on their official website: https://www.elso.org/

Conclusion

There is no single numerical age limit for ECMO. A patient's eligibility is determined through a careful, comprehensive assessment of numerous factors, including the reversibility of their condition, overall health, and comorbidities. While older age is associated with increased mortality risk, it does not automatically disqualify a patient. ECMO is a life-saving but high-risk therapy, and the decision to proceed is a complex one, made by a multidisciplinary team on a case-by-case basis. Ultimately, the focus is on whether the patient has a chance of recovering and regaining a meaningful quality of life.

Frequently Asked Questions

Yes, an elderly person can receive ECMO. Age is considered a relative, not absolute, contraindication. The decision depends more on their overall health, the reversibility of their condition, and the presence of any comorbidities that might affect their prognosis.

While not a hard limit, age is a factor because older patients generally have lower physiological reserves and more comorbidities, which can increase the risk of complications and mortality during and after ECMO. The decision balances these risks against the potential for recovery.

Yes. While ECMO is a well-established therapy for neonates, historical criteria focused on a minimum gestational age (>34 weeks) and weight (>2kg) due to risks like intracranial hemorrhage. For children, vessel size can also be a consideration for cannula placement.

The most important factor is the potential for the patient's underlying heart or lung failure to be reversible. If the condition is not treatable and the organs will not recover, ECMO is not appropriate, as it is a bridge to recovery, not a permanent solution.

Yes, a prolonged period of high-pressure mechanical ventilation before starting ECMO can be a relative contraindication. It suggests the lungs may have sustained significant damage, which reduces the chance of a successful outcome.

The decision is made by a multidisciplinary team that can include intensive care physicians, surgeons, perfusionists, nurses, and respiratory therapists. This team approach ensures a comprehensive evaluation of the patient's condition and prognosis.

ELSO is an international organization that collects data and provides guidelines for ECMO use. They do not set specific age limits, acknowledging that patient outcomes are too variable to be determined by a single age threshold.