Do we need new indications for ECMO in neonates pretreated with high-frequency ventilation and/or inhaled nitric oxide?

Intensive Care Med. 2000 Oct;26(10):1489-95. doi: 10.1007/s001340000603.

Abstract

Objective: High-frequency ventilation (HFV) and/or inhaled nitric oxide (iNO) has reduced ECMO in neonates. But, frequently, improvement with HFV/iNO is temporary and only prolongs lung injury without preventing ECMO. We tried to identify a threshold oxygenation index (OI) that predicts temporary or persistent improvement with HFV/iNO in neonatal ECMO candidates as early as possible.

Design: Cohort study of all neonates with OI > 40 during intermittent positive pressure ventilation between 1992 and 1997. The first treatment was HFV; at an OI > 40 during HFV, iNO was added; at an OI > 40 during HFV+iNO, ECMO was initiated. Temporary improvement was defined as secondary need for ECMO or fatal chronic lung disease without ECMO.

Setting: University hospital level III neonatal intensive care unit.

Main results: Ten of the 34 neonates studied rapidly required ECMO despite HFV/iNO. Eleven neonates temporarily improved for 1-10 days before the OI was again > 40. Nine received ECMO, two were denied ECMO after mechanical ventilation > 14 days and died of chronic lung disease. Thirteen neonates persistently improved with HFV/iNO without ECMO. The OI before, at 24 h or 48 h of HFV/iNO did not predict temporary or persistent improvement. However, after 72 h of HFV/iNO, neonates with persistent improvement had lower OIs than those with temporary improvement [median OI 16 (4-24) vs 31 (20-40); P = 0.0004]. In all neonates with an OI > or = 25 after 72 h, HFV/iNO eventually failed (positive predictive value 100%, sensitivity 91 %, specificity 100%, positive likelihood ratio 91).

Conclusion: For neonates pretreated with HFV/iNO, an OI > 40 is an inadequate ECMO indication. Based on our data we hypothesize that an OI > or = 25 after 72 h of HFV/ iNO is a better ECMO indication that avoids prolonged barotrauma.

Publication types

  • Validation Study

MeSH terms

  • Administration, Inhalation
  • Algorithms
  • Blood Gas Analysis
  • Combined Modality Therapy
  • Decision Trees
  • Extracorporeal Membrane Oxygenation / methods*
  • High-Frequency Ventilation / methods*
  • Humans
  • Infant
  • Infant, Newborn
  • Intensive Care, Neonatal / methods*
  • Intermittent Positive-Pressure Ventilation / methods
  • Monitoring, Physiologic / methods*
  • Nitric Oxide / pharmacology
  • Nitric Oxide / therapeutic use*
  • Oxygen / blood*
  • Patient Selection*
  • Premedication / methods*
  • Prospective Studies
  • Pulmonary Circulation / drug effects
  • Respiratory Distress Syndrome, Newborn / blood*
  • Respiratory Distress Syndrome, Newborn / mortality
  • Respiratory Distress Syndrome, Newborn / physiopathology
  • Respiratory Distress Syndrome, Newborn / therapy*
  • Sensitivity and Specificity
  • Treatment Outcome
  • Vascular Resistance / drug effects
  • Vasodilator Agents / pharmacology
  • Vasodilator Agents / therapeutic use*

Substances

  • Vasodilator Agents
  • Nitric Oxide
  • Oxygen