Awake Neonatal Extracorporeal Membrane Oxygenation

Abstract

Extracorporeal membrane oxygenation (ECMO) is used in patients with acute respiratory failure that is not responsive to conventional management. The practice of awake ECMO has become an area of interest but with limited data and experience. Most reported experience comes from adult and pediatric populations. Traditional management of these patients still includes mechanical ventilator support and often requires the use of sedatives for provision of safe care. We present a series of eight neonates who were electively extubated while on ECMO, with expanded discussion of two representative cases. We discuss the rationale for extubation and outcomes. The greatest benefit of this management was seen in patients with significant air leak, and in no reported case did we experience any adverse effects or complications as a direct result of extubation while on ECMO. In conclusion, in our experience, awake neonatal ECMO appears safe and effective and may offer significant advantages over traditional management in certain clinical scenarios. Prospective comparison trials are warranted to further investigate the clinical benefits and risks of awake neonatal ECMO.

Neonatal respiratory and cardiac ECMO in Europe

“…Serial lung mechanics measurements, such as the forced oscillation technique, may be used to titrate ventilatory support and chest physiotherapy, and support either lung recruitment maneuver and pharmacological treatment [91]. Extubation may be feasible during neonatal ECMO [92].…”

Ventilation Strategies During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure: Current Approaches Among Level IV Neonatal ICUs

“…The practice of extubating patients on ECMO for maximal lung protection and encouraging spontaneous lung recruitment is much more commonplace in the adult ECLS population, with limited reported experience in neonates. Although our survey did not inquire about the reasons for this practice, there may be a subset of patients (e.g., severe or refractory air leak) who could benefit from this approach (22, 23). A recent case series of eight neonates electively extubated during neonatal respiratory ECMO reported effective resolution of lung disease and successful decannulation of all patients (22).…”

Pediatric and neonatal extracorporeal life support: current state and continuing evolution

“…Its use has grown among adult patients but reports in pediatric patients are limited [23][24][25][150][151][152]. Recent series have demonstrated the feasibility of awake ECLS in pediatric patients as young as 2 days old as both a bridge to recovery and a bridge to transplant [153][154][155] (Fig. 4).…”

“…4). Costa et al noted a particular benefit of extubation for neonatal patients with persistent air leaks, avoiding positive pressure, and expediting the healing of the leak without the need for tube thoracostomy [155]. Cannulation for ECLS can also be done in an awake, non-intubated patient, which is a valuable approach to the management of impending respiratory failure due to airway obstruction [156,157].…”

“…They have shown good success with routine enteral feeding despite inotrope support [171,172] with potentially improved survival [172] and no major complications [171][172][173]. When combined with awake ECLS, neonatal patients can actually bottle feed to promote normal oral intake [155].…”