Extracorporeal life support for severe pediatric respiratory failure: An updated experience 1991–1993

doi:10.1016/S0022-3476(05)83174-9

The Journal of Pediatrics

Volume 124, Issue 6, June 1994, Pages 875-880

https://doi.org/10.1016/S0022-3476(05)83174-9 Get rights and content

Objective:

The purpose of this study was to examine our recent experience with children who had acute respiratory failure managed with extracorporeal life support (ECLS) from 1991 to 1993, to determine whether a change in survival rate had occurred in comparison with our previous experience.

Design: Historic and prospective cohort study.

Setting: A tertiary pediatric referral center.

Patients: All nonneonatal pediatric patients treated with ECLS for severe, life-threatening respiratory failure were examined. Overall, 25 patients have been managed with this life-support technique in the past 28 months. Eighty-four percent (21/25) were transferred to our medical center because of failure of conventional mechanical ventilation therapy. Descriptive data of the recent cohort were as follows (mean ± SD): age 60±75 months, weight 23.6±24.8 kg, and male gender 44%. Duration of intubation before ECLS was 5.8±2.7 days. Arterial blood gas values and ventilator settings immediately before ECLS were as follows: fraction of inspired oxygen, 0.98±0.08; mean airway pressure, 21.6±6.2 cm H₂O; peak inspiratory pressure, 45.5±9.6 cm H₂O; positive endexpiratory pressure, 11.0±4.3 cm H₂O; partial pressure of oxygen (arterial), 56±20 mm Hg (7.4±2.7 kilopascals); partial pressure of carbon dioxide (arterial), 46±17 mm Hg (6.1±2.3 kPa); and estimated alveolar-arterial oxygen tension difference, 572±81 mm Hg (76.3±10.8 kPa). Mean duration of ECLS was 373±259 hours. Of 25 recently treated patients, 22 (88%) survived their lifethreatening respiratory illness to be discharged home; this represented a statistically improved survival rate in comparison with the 58% survival rate previously reported by us for similar patients (p<0.05). Comparisons of arterial blood gas and mechanical ventilation-related variables measured 24 hours before and again immediately before bypass were similar in the two cohorts with the exception of higher mean partial pressure of carbon dioxide (arterial) 24 hours before bypass in the recent treatment group. For our entire experience, younger age groups had greater survival rates; 100% of infants less than 1 year of age survived.

Conclusions: Treatment with ECLS is an evolving pulmonary rescue therapy with an 88% survival rate in our recent experience. The survival rate has improved to levels that may not greatly improve in the near future, especially for patients less than 1 year of age. Better patient selection or improved management strategies or both may be responsible for the improved patient outcome.

References (20)

KatzR et al.
Cardiorespiratory abnormalities in severe acute respiratory failure
J Pediatr
(1984)
PfenningerJ et al.
Adult respiratory distress syndrome in children
J Pediatr
(1982)
HolbrookPR et al.
Adult respiratory distress syndrome in children
Pediatr Clin North Am
(1980)
TimmonsOD et al.
Mortality rates and prognostic variables in children with adult respiratory distress syndrome
J Pediatr
(1991)
TamburroRF et al.
Alveolar-arterial oxygen gradient as a predictor of outcome in patients with nonneonatal pediatric respiratory failure
J Pediatr
(1991)
DavisSL et al.
Adult respiratory distress syndrome in children: associated disease, clinical course, and predictors of death
J Pediatr
(1993)
AdolphV et al.
Extracorporeal membrane oxygenation for nonneonatal respiratory failure
J Pediatr Surg
(1991)
MolerFW et al.
Predictors of outcome for severe respiratory syncytial virus-associated respiratory fallure treated with extracorporal membrane oxygenation
J Pediatr
(1993)
LyreneRK et al.
Adult respiratory distress syndrome in a pediatric intensive care unit
Pediatrics
(1981)
NussbaumE
Adult-type respiratory distress syndrome in children
Clin Pediatr
(1983)

There are more references available in the full text version of this article.

Cited by (55)

Factors associated with survival in pediatric extracorporeal membrane oxygenation - A single-center experience
2010, Journal of Pediatric Surgery
Citation Excerpt :
Extracorporeal membrane oxygenation is sporadically used in children with severe respiratory or cardiopulmonary failure secondary to a variety of causes such as acute hypoxemic respiratory failure, sepsis, trauma, immunosuppression, burns, bleeding disorders, and multiple organ systems failure [10-12]. Due to differences in patient selection, pre-ECMO patient characteristics and ECMO practice, the survival rates after pediatric ECMO are not uniform across centers [13-15]. Unlike the neonatal population, bedside decisions for the pediatric population are unlikely to be instructed by randomized controlled trials in the near future.
We aimed to examine outcomes of extracorporeal membrane oxygenation (ECMO) therapy in the pediatric population and identify pre-ECMO and on-ECMO characteristics that are associated with survival.
We retrospectively reviewed the ECMO records at our institution between 1999 and 2008 and selected pediatric patients who were cannulated for respiratory failure or hemodynamic instability resistant to conventional interventions. We recorded details of pre-ECMO clinical characteristics, including blood gas variables and mechanical ventilatory support, and details of ECMO therapy including survival off ECMO and to hospital discharge. Predictors of survival were analyzed using logistic regression modeling and a prediction algorithm was developed.
Of the 445 ECMO runs, data from 58 consecutive patients were analyzed: 57% were successfully decannulated, and 48% survived to discharge from the hospital. The cohort included 32 (55%) female patients, 22 postoperative patients (38%), and 15 (26%) with an immunosuppressive condition, with a median age of 5 years and weight 19.5 kg, The mean duration of pre-ECMO respiratory support was 3 days, in the form of high-frequency oscillatory ventilation (n = 28, 48%) and conventional mechanical ventilation (n = 13, 22%). The median duration (interquartile range) of ECMO support was 142 hours (60, 321) or 5.9 days. Pre-ECMO pH above 7.2 (P < .001) and oxygenation index below 35 (P = .021) were associated with the highest survival rates. Pre-ECMO Paco₂ and duration of mechanical ventilation were not associated with survival.
Based on our results, ECMO therapy should be considered early in children with oxygenation index greater than 35 with worsening metabolic status. The restriction of ECMO based on ventilator days alone needs to be revisited in this era of lung protective ventilation.
Extracorporeal Life Support for Cardiopulmonary Failure
2006, Pediatric Surgery: Sixth Edition
Systemic hypertension associated with venovenous extracorporeal membrane oxygenation for pediatric respiratory failure
2004, Journal of Pediatric Surgery
Arterial hypertension (HTN) is common in neonates on venoarterial (VA) extracorporeal membrane oxygenation (ECMO), but HTN in pediatric venovenous (VV) ECMO has not been well described. The authors noted HTN in their VV ECMO experience and hypothesized that HTN was associated with fluid status, steroid use, and renal insufficiency.
Records of 50 patients receiving VV ECMO for respiratory failure were reviewed. HTN was defined as systolic blood pressure greater than 95th percentile for age for ≥1 hour, unresponsive to sedation/analgesia. Hypertensive index (HI) is defined as total hypertensive hours per total ECMO hours. Fluid status was estimated by a fluid index (FI = total fluid balance during ECMO per ECMO hours per weight).
Forty-seven of 50 patients (94%) had HTN. Median HI was 0.21 (range, 0.01 to 1.0). Thirteen patients had renal insufficiency, 39 received steroids, and 23 received continuous venovenous hemofiltration (CVVH). There was no association between HI and FI, steroid use, or renal insufficiency. Thirty-three patients were treated for HTN, often requiring multiple agents. Bleeding complicated the course of 18 patients, and HI was significantly higher in those patients (P = .03). HI was not different between survivors (37 of 39 with HTN) and nonsurvivors (10 of 11 with HTN).
Hypertension is a common complication associated with VV ECMO with unclear etiology. HTN was frequently difficult to control. This study emphasizes the need for the development of treatment protocols to decrease the incidence, severity, and associated morbidity. Improved insight into the etiology of HTN associated with pediatric VV ECMO, including evaluation of the renin-angiotensin system, would help guide therapy.
The use of surfactant in children with acute respiratory distress syndrome: Efficacy in terms of oxygenation, ventilation and mortality
2003, Pulmonary Pharmacology and Therapeutics
Purpose. The aim of this prospectively designed study was to investigate the efficacy of surfactant (S) for acute respiratory distress syndrome (ARDS) in children.
Materials and methods. Children with ARDS were included in this study. Surfactant (Survanta, Abbott, USA) was given intratracheally at a dose of 150 mg/kg every 12 h for a total of two doses. During the study period none of the patients received permissive hypercapnia, high frequency ventilation, nitric oxide or ECMO. Peak inspiratory pressure (PIP), positive end expiratory pressure (PEEP), ventilation rate, mean airway pressure, tidal volume (TV), Murray index, PaO₂/FiO₂, ventilation index (VI), oxygen index (OI) and arterial oxygen tension difference (A-aDO₂) were measured before and 48 h after surfactant treatment. Duration of mechanical ventilation therapy, duration in paediatric intensive care unit (PICU) and mortality rate were recorded.
Results. Among the 36 children who met the inclusion criteria, 12 were treated with surfactant. The mean age was 72.5±56.2 months; 47% of children were male. Infants were ventilated by pressure-controlled ventilators whereas for older children volume-controlled ventilators were used. Sepsis (42%) was the main predisposing factor followed by pneumonia (25%) and malignancy (17%). The baseline characteristics including age, predisposing factors, gender, PIP, PEEP, A-aDO₂, PaO₂/FiO₂, OI, TV, VI and Murray index were similar in the surfactant and non-surfactant (NS) group (p>0.05). There were significant improvements in PIP, PEEP, A-aDO₂, PaO₂/FiO₂, OI, TV, VI and Murray index in the surfactant group after surfactant treatment compared with NS group (p<0.05). Duration of PICU stay and ventilator treatment was longer in NS group (14±3.7, 1.8±3.2 days vs. 9.2±3.1, 8.6±1.9 days), (p<0.05). Mortality rate was 42% in surfactant compared with 63% in the NS group, (p>0.05). Children in the surfactant group lived significantly longer (p<0.05).
Conclusions. Modified natural surfactant is an effective treatment option in children with ARDS for improving gas exchange, decreasing the use of ventilatory support and increasing survival time.
Results of an artificial-lung survey to lung transplant program directors
2002, Journal of Heart and Lung Transplantation
Lung transplantation is the only treatment for patients with end-stage lung disease. However, the scarcity of donor organs illustrates the need for alternatives. Recent success in the use of ventricular assistance has stimulated research in technology designed as a bridge to lung transplantation. Some laboratories have demonstrated significant advances in the development of artificial lungs, and clinical applications are on the horizon. In preparation, we sought to gather information from the lung transplant community regarding issues related to testing and potential trials of artificial lungs.
We constructed a survey and distributed it to lung transplant program directors recognized by the United Network for Organ Sharing. Topics included required animal studies, preferred designs, logistics of clinical trials, and patient diagnoses most appropriate for such a trial.
The 31 programs responding to the survey performed 72% of all lung transplants in the United States in 1999. Ninety-seven percent supported a Phase I trial using an artificial lung as a bridge to lung transplantation. Additionally, 58% specifically supported a trial in which organ allocation would be prioritized to enrolled patients. Idiopathic pulmonary fibrosis was the diagnosis thought most appropriate for inclusion in initial clinical trials.
Widespread support exists for the development and use of an artificial lung as a bridge to lung transplantation. Information from transplant centers regarding device design and application can influence laboratories developing artificial lungs, and such communication will be essential as this technology progresses from the bench-top to the bedside.
Lung salvage and protection ventilatory techniques
2001, Pediatric Clinics of North America
Citation Excerpt :
Outcome figures for pediatric ECMO based on the ELSO registry figures are not nearly as good as for neonates, with an overall survival rate of approximately 40% to 50%. Single-institution survival rates of as high as 70% to 80%92,128,141,149 have been reported. The problem with interpreting these sorts of outcome data is that they are center specific and do not account for widely different ventilation practices.
Since the first report of the use of positive-pressure ventilation (PPV) during the polio epidemic of the 1950s, the principles that governed the use of mechanical ventilation were based more on art than science and were founded on applying the rules of normal physiology. Little changed in the succeeding 30 years, and despite innovations in ventilator technology, the mortality rate among patients in acute hypoxic respiratory failure (AHRF) remained high.24, 27, 108, 116, 132, 133 It was not until the introduction of high-frequency ventilation in the 1970s that people began to question whether mimicking normal physiology was the best strategy in managing the injured lung. Added impetus has come from animal experiments demonstrating ventilator-associated lung injury (VALI), even in healthy lungs. Clinicians now are seeing the most fundamental process of re-evaluation of mechanical ventilation practices since the therapy first was introduced into clinical practice. This re-evaluation takes into account that the mechanical ventilator was part of the problem and part of the solution. Many of the new techniques adopted in adult and pediatric practice have been pioneered and tested in children. This adaptation serves to emphasize that there is a commonality to the pathophysiology of lung injury that crosses the age spectrum.
Acute respiratory failure (ARF) in children may be catagorized broadly into lung disease of neonates and infants, in whom it usually is a single-system disease process involving only the lung, whereas in older children, pulmonary failure is commonly a part of a multiple system dysfunction syndrome that is entirely similar to adults with the acute respiratory distress syndrome (ARDS). In multiple system dysfunction, outcome may be related more closely to the ventilation strategy or adjunctive therapies used to manage the pulmonary dysfunction, while in ARDS, these therapies commonly have less impact because outcome is more related to the development of multiorgan dysfunction syndrome. Consequently, therapies that target the lung, such as high-frequency ventilation, surfactant, and inhaled nitric oxide (iNO), are more likely to affect the outcome of infants with AHRF compared with older children.

View all citing articles on Scopus

¹: Presented in part at the Extracorporeal Life Support Organization Fifth Annual Meeting, Dearborn, Mich., Oct. 1–3, 1993, and the Society of Critical Care Medicine's 23rd Annual Educational and Scientific Symposium, Orlando, Fla., Jan. 31 to Feb. 3, 1994.

View full text

Original articleExtracorporeal life support for severe pediatric respiratory failure: An updated experience 1991–19931

Objective:

J Pediatr

J Pediatr

Pediatr Clin North Am

J Pediatr

J Pediatr

J Pediatr

J Pediatr Surg

J Pediatr

Adult respiratory distress syndrome in a pediatric intensive care unit

Pediatrics

Adult-type respiratory distress syndrome in children

Clin Pediatr

Original article
Extracorporeal life support for severe pediatric respiratory failure: An updated experience 1991–19931