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


METHODS
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.


METHODS
University hospital level III neonatal intensive care unit.


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).


CONCLUSIONS
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.
Kössel
H
H
Department of Pediatrics, Klinikum Benjamin Franklin, Freie Universität Berlin, Germany.
Bauer
K
K
Kewitz
G
G
Karaca
S
S
Versmold
H
H
D000280:Administration, Inhalation; D000465:Algorithms; D001784:Blood Gas Analysis; D003131:Combined Modality Therapy; D003663:Decision Trees; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D006612:High-Frequency Ventilation / Q000379:methods*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015931:Intensive Care, Neonatal / Q000379:methods*; D007385:Intermittent Positive-Pressure Ventilation / Q000379:methods; D008991:Monitoring, Physiologic / Q000379:methods*; D009569:Nitric Oxide / Q000494:pharmacology / Q000627:therapeutic use*; D010100:Oxygen / Q000097:blood*; D018579:Patient Selection; D011292:Premedication / Q000379:methods*; D011446:Prospective Studies; D011652:Pulmonary Circulation / Q000187:drug effects; D012127:Respiratory Distress Syndrome, Newborn / Q000097:blood* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D012680:Sensitivity and Specificity; D016896:Treatment Outcome; D014655:Vascular Resistance / Q000187:drug effects; D014665:Vasodilator Agents / Q000494:pharmacology / Q000627:therapeutic use*
D014665:Vasodilator Agents; D009569:Nitric Oxide; D010100:Oxygen