High-Frequency Oscillatory Ventilation and Extracorporeal Membrane Oxygenation for the Treatment of Acute Neonatal Respiratory Failure

Abstract

Forty-six (92%) outborn and four (8%) in-born term or near-term neonates were admitted for extracorporeal membrane oxygenation (ECMO) treatment to a neonatal intensive care unit between July 1, 1985, and November 1, 1987. All infants had Pao2 - Pao2 ≥ 600 mm Hg in spite of aggressive conventional ventilatory and pharmacologic therapy. All patients were offered rescue treatment with high-frequency oscillatory ventilation (HFOV), and only if there was no improvement in Pao2 Pao2 with HFOV were infants treated using ECMO. Four patients died before receiving an adequate trial of HFOV and before emergency ECMO support could be initiated; 21 patients, all of whom survived to hospital discharge, responded to HFOV; 25 patients ultimately required ECMO therapy for cardiopulmonary support, with 22 (88%) surviving to discharge. Neonates responding to HFOV were of slightly younger gestational age (38 ± 2 weeks vs 40 ± 2 weeks, mean ± SD; P < .001) and more frequently had clinical evidence of pneumonia (11 of 21 vs 2 of 25; P < .002). There was no statistically significant difference in outcome with respect to the number of ventilator days, hospital days, or survival between patients responding to HFOV and patients who required ECMO. Morbidity was increased in ECMO patients, with bleeding abnormalities, seizures, and renal failure occurring more frequently than in HFOV-treated infants. Overall, 92% (46 of 50) of the patients were treated with a staged protocol using HFOV before ECMO. A total of 46% (21 of 46) responded to HFOV treatment alone and did not require ECMO therapy. This study demonstrates that a substantial proportion of extremely ill term and near-term infants who did not respond to conventional supportive measures could be successfully treated with HFOV. Alternate, staged, or combined treatment modalities may allow greater flexibility in directing life-support therapy toward specific cardiopulmonary disease, while maintaining for the patient the best possible risk to benefit ratio.