High frequency oscillatory ventilation and extracorporeal membrane oxygenation in severe persistent pulmonary hypertension of the newborn

Abstract

We report on 50 term and near-term neonates (birth weight greater than 1800 g, gestational age greater than 33 weeks) with severe persistent pulmonary hypertension of the newborn (PPHN), referred to us from January 1987 to July 1991 after failure of maximum conventional treatment. All infants had paO2 less than 45 mm Hg when ventilated with peak inspiratory pressure greater than 38 cm H2O and FiO2 = 1.0, hence meeting entry criteria for extracorporeal membrane oxygenation (ECMO). High frequency oscillatory ventilation (HFOV) was tried in all patients. If sufficient oxygenation could not be achieved (paO2 less than 40 mm Hg for at least 2 h), ECMO therapy was begun, which was the case in 25 children. Neonates responding to HFOV (n = 25) were of a slightly younger gestational age (37.0 weeks vs 38.8 weeks, P less than 0.05), had higher Apgar scores and were less hypoxaemic before HFOV (paO2 36.6 mm Hg vs 28.8 mm Hg, P less than 0.01); during HFOV there was a significant rise in paO2 (greater than 150 mm Hg; P less than 0.001) and a fall in pCO2 to 21.6 mm Hg (P less than 0.001). Due to air leaks, which was the main complication of HFOV (52%), ECMO therapy had to be begun in two additional infants after an initial positive effect. HFOV tended to be successful in cases of primary PPHN, meconium aspiration and sepsis, but not in infants with lung hypoplasia as a result of diaphragmatic hernia or other reasons. Success or failure of HFOV could not be reliably predicted by any parameter.(ABSTRACT TRUNCATED AT 250 WORDS)

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

“…Though the use of HFV and iNO have reduced the use of ECMO, 40 % [12], 39 % [11], and 38 % [13], of the neonates treated with iNO were non-responders and required ECMO. Of the neonates treated with HFV, 50 % [2] and 40 % [1] were non-responders and required ECMO; in our study 11 of 24 neonates (46 %) were non-responders. For these non-responders the HFV/iNO trial only prolonged mechanical ventilation and barotrauma but did not avoid ECMO.…”

“…In a prospective randomized trial HFV was successful in 48 % of neonatal ECMO candidates whereas continued IPPV only in 26 % [1]. Only about 50 % of neonates meeting criteria for ECMO required ECMO after a trial of HFV in prospective cohort studies [2,4]. iNO reduced the need for ECMO in neonatal respiratory failure in three randomized controlled trials by 15 % [11], 31 % [12], and 26 % [13], respectively.…”

“…We used a flow-interrupter type ventilator for HFV in some infants, in conjunction with IPPV. Other HFV modes used in pre-ECMO treatment were high-frequency oscillatory ventilation with IPPV [2] and without IPPV [14] and highfrequency jet ventilation in conjunction with IPPV [9]. At present there is no scientific proof that one HFV mode is superior to the other [15].…”

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IntroductionThe introduction of high-frequency ventilation (HFV) and of inhaled nitric oxide (iNO) have reduced the need for ECMO in neonates with acute respiratory failure [1,2,3,4,5,6,7]. About 50 % of the neonates initially respond to HFV and/or iNO, but failure rates (defined as secondary indication for ECMO or death without ECMO) of HFV and iNO between 13 % and 30 % were reported [1,2,3,4,5,6,7].

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“…About 50 % of the neonates initially respond to HFV and/or iNO, but failure rates (defined as secondary indication for ECMO or death without ECMO) of HFV and iNO between 13 % and 30 % were reported [1,2,3,4,5,6,7]. For these neonates, the unsuccessful trial of HFV/iNO means additional barotrauma before ECMO is initiated, or the prolongation of mechanical ventilation can even exclude subsequent ECMO therapy.…”