Abstract
BACKGROUND: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used when mechanical ventilation can no longer support oxygenation or ventilation, or if the risk of ventilator-induced lung injury is considered excessive. The optimum mechanical ventilation strategy once on ECMO is unknown. We sought to describe the practice of mechanical ventilation in children on VV-ECMO and to determine whether mechanical ventilation practices are associated with clinical outcomes.
METHODS: We conducted a multicenter retrospective cohort study in 10 pediatric academic centers in the United States. Children age 14 d through 18 y on VV-ECMO from 2011 to 2016 were included. Exclusion criteria were preexisting chronic respiratory failure, primary diagnosis of asthma, cyanotic heart disease, or ECMO as a bridge to lung transplant.
RESULTS: Conventional mechanical ventilation was used in about 75% of children on VV-ECMO; the remaining subjects were managed with a variety of approaches. With the exception of PEEP, there was large variation in ventilator settings. Ventilator mode and pressure settings were not associated with survival. Mean ventilator FIO2 on days 1–3 was higher in nonsurvivors than in survivors (0.5 vs 0.4, P = .009). In univariate analysis, other risk factors for mortality were female gender, higher Pediatric Risk Estimate Score for Children Using Extracorporeal Respiratory Support (Ped-RESCUERS), diagnosis of cancer or stem cell transplant, and number of days intubated prior to initiation of ECMO (all P < .05). In multivariate analysis, ventilator FIO2 was significantly associated with mortality (odds ratio 1.38 for each 0.1 increase in FIO2, 95% CI 1.09-1.75). Mortality was higher in subjects on high ventilator FIO2 (≥ 0.5) compared to low ventilator FIO2 (> 0.5) (46% vs 22%, P = .001).
CONCLUSIONS: Ventilator mode and some settings vary in practice. The only ventilator setting associated with mortality was FIO2, even after adjustment for disease severity. Ventilator FIO2 is a modifiable setting that may contribute to mortality in children on VV-ECMO.
- artificial respiration
- extracorporeal membrane oxygenation
- pediatrics
- acute respiratory distress syndrome
- ventilator-induced lung injury
- oxygen
Footnotes
- Correspondence: Matthew L Friedman MD, Phase 2, Room 4900, 705 Riley Hospital Drive, Indianapolis, IN 46202. E-mail: friedmml{at}iu.edu
Dr Friedman presented a version of this paper at the Extracorporeal Life Support Organization Annual Conference, held September 13–16, 2018, in Scottsdale, Arizona.
This study was supported financially by grants from the Extracorporeal Life Support Organization and the Pediatrics Department at Indiana University School of Medicine. Dr Barbaro discloses relationships with Extracorporeal Life Support Organization Registry and NHLBI, and the NIH. Dr Bembea discloses relationships with the NIH NICHD and NINDS. Dr Cheifetz discloses relationships with Philips, Up-to-Date, and the NHLBI. The remaining authors have disclosed no conflicts of interest.
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