Advances and Challenges in Artificial Womb for Respiratory Support in Extremely Low Gestational Age Neonates: A Narrative Review.

BACKGROUND: Respiratory management of extremely low gestational age neonates (ELGANs) is a major challenge in neonatal intensive care, as they face high mortality and morbidity due to complications such as respiratory distress syndrome and bronchopulmonary dysplasia. Traditional respiratory support methods (e.g., mechanical ventilation) have limitations, potentially leading to adverse outcomes like chronic lung injury and intracranial hemorrhage. Artificial womb technology (AWT), based on extracorporeal membrane oxygenation (ECMO) principles, has emerged as a potential alternative by simulating the intrauterine environment to provide respiratory and circulatory support for ELGANs.

METHODS: This narrative review systematically summarizes the development of AWT for respiratory support in ELGANs, analyzes its core technical principles (e.g., pumpless arteriovenous extracorporeal life support (V-A ECLS) and pump-driven veno-venous extracorporeal life support (V-V ECLS)), and explores key advancements and challenges in oxygenator design, anticoagulation strategies, cannulation techniques, and synthetic amniotic fluid regulation.

RESULTS: Significant progress has been made in AWT over the past decade, with two main support modes (pumpless and pump-driven) developed, each showing advantages and disadvantages in gas exchange efficiency and animal model survival time. Improvements in oxygenator materials (e.g., hollow fiber membranes, polymethylpentene membranes) and miniaturized designs have optimized gas exchange and reduced priming volume. Advances in anticoagulation strategies (e.g., heparin alternatives, surface coating technologies) and monitoring systems (e.g., nano-sensors, near-infrared spectroscopy) have enhanced safety. Additionally, regulation of synthetic amniotic fluid composition and immunomodulatory mechanisms has preliminarily simulated the intrauterine environment, but issues such as intracranial hemorrhage and species-specific barriers in animal model translation remain.

CONCLUSIONS: AWT offers a new direction for respiratory support in ELGANs, but its clinical application requires addressing challenges in biocompatibility, long-term organ development monitoring, and ethical norms. With optimized system design, material innovation, and multimodal monitoring, AWT is expected to become a crucial tool for improving ELGANs' prognosis.