Lung Rest During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure—Practice Variations and Outcomes

Abstract

Objective Describe practice variations in ventilator strategies used for lung rest during extracorporeal membrane oxygenation (ECMO) for respiratory failure in neonates, and assess the potential impact of various lung rest strategies on the duration of ECMO and the duration of mechanical ventilation after decannulation. Data Source Retrospective cohort analysis from the extracorporeal life support organization (ELSO) registry database during the years 2008–2013. Study selection All ECMO runs for infants ≤ 30 days of life for pulmonary reasons were included. Data extraction Ventilator type and ventilator settings used for lung rest at 24 hours after ECMO initiation were obtained. Results A total of 3,040 cases met inclusion criteria. Conventional mechanical ventilation (CMV) was used for lung rest in 88% of cases and high frequency ventilation (HFV) was used in 12%. In the CMV group, 32% used positive end expiratory pressure (PEEP) strategy of 4–6 cm H2O (low), 22% used 7–9 cm H2O (mid) and 43% used 10–12 cm H2O (high). HFV was associated with an increased mean (SEM) hours of ECMO [150.2 (0.05) vs. 125 (0.02); p < 0.001] and an increased mean (SEM) hours of mechanical ventilation after decannulation [135 (0.09) vs. 100.2 (0.03); p = 0.002], compared with CMV among survivors. Within the CMV group, use of higher PEEP was associated with a decreased mean (SEM) hours of ECMO [high vs. low: 136 (1.06) vs. 156 (1.06), p = 0.001; mid vs. low: 141 (1.06) vs. 156 (1.06); p = 0.04] but increased duration of mechanical ventilation after decannulation in the high PEEP group compared with low PEEP (p= 0.04) among survivors. Conclusions Wide practice variation exists with regard to ventilator settings used for lung rest during neonatal respiratory ECMO. Use of HFV as compared to CMV and use of low PEEP strategy as compared to mid PEEP and high PEEP strategy is associated with longer duration of ECMO. Further research to provide evidence to drive optimization of pulmonary management during neonatal respiratory ECMO is warranted.

Mechanical Ventilation in Children on Venovenous ECMO

“…We noted higher use of nonconventional modes during ECMO than reported previously, although most adult studies of mechanical ventilation on ECMO have used conventional mechanical ventilation exclusively, with a few recent studies reporting small number of subjects on airway pressure release ventilation. [6][7][8][9][10][11]17,27 Neonates on ECMO predominantly receive conventional mechanical ventilation (88%). 11 There was variability in some ventilator settings, including F IO 2 and mean airway pressure ( P aw ).…”

“…[6][7][8][9][10][11]17,27 Neonates on ECMO predominantly receive conventional mechanical ventilation (88%). 11 There was variability in some ventilator settings, including F IO 2 and mean airway pressure ( P aw ). The median values of F IO 2 and P aw in our study were lower than reported in adult studies, but the variability was similar.…”

“…Adult and neonatal studies have reported wider variability in PEEP than observed in our study, with adults tending to be supported on higher PEEP and neonates on lower PEEP. [6][7][8][9][10][11] Most subjects in the study had a PIP of 20 cm H 2 O, which was the median and 25th percentile values on ECMO day 1 and day 3. The PIP used in children in this study is lower than what has been used in most adult studies.…”

“…4,5 Mechanical ventilation strategies in adult and neonatal subjects with acute respiratory failure have been studied. [6][7][8][9][10][11][12][13][14] Conversely, there has been little study of mechanical ventilation in children on ECMO support for respiratory failure, and there are no evidence-based or expert consensus guidelines. 15,16 Ventilator management on ECMO has historically focused on a "lung rest" strategy to limit ventilator-induced lung injury.…”

Extracorporeal Membrane Oxygenation Support in Neonates: A Single Center Experience in Turkey

“…In a recent cohort study, it was shown that the use of HFV compared with conventional mechanical ventilation (MV) for lung rest during ECMO support is associated with longer duration of ECMO and MV (24). We used conventional MV modes for lung rest strategies during ECMO run for all our patients, regardless of their illness type and severity.…”