Ventilation Strategies During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure: Current Approaches Among Level IV Neonatal ICUs

John Ibrahim, MD; Burhan Mahmood, MD; Robert DiGeronimo, MD; Natalie E. Rintoul, MD; Shannon E. Hamrick, MD; Rachel Chapman, MD; Sarah Keene, MD; Ruth B. Seabrook, MD; Zeenia Billimoria, MD; Rakesh Rao, MD; John Daniel, MD; John Cleary, MD; Kevin Sullivan, MD; Brian Gray, MD; Mark Weems, MD; Daniel R. Dirnberger, MD; for the CHNC ECMO Focus Group

doi:10.1097/CCE.0000000000000779

Critical Care Explorations (Nov 2022)

Ventilation Strategies During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure: Current Approaches Among Level IV Neonatal ICUs

John Ibrahim, MD,
Burhan Mahmood, MD,
Robert DiGeronimo, MD,
Natalie E. Rintoul, MD,
Shannon E. Hamrick, MD,
Rachel Chapman, MD,
Sarah Keene, MD,
Ruth B. Seabrook, MD,
Zeenia Billimoria, MD,
Rakesh Rao, MD,
John Daniel, MD,
John Cleary, MD,
Kevin Sullivan, MD,
Brian Gray, MD,
Mark Weems, MD,
Daniel R. Dirnberger, MD,
for the CHNC ECMO Focus Group

Affiliations

John Ibrahim, MD: 1 UPMC Children’s Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA.
Burhan Mahmood, MD: 1 UPMC Children’s Hospital of Pittsburgh and Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA.
Robert DiGeronimo, MD: 2 Department of Pediatrics, Seattle Children’s Hospital and University of Washington, Seattle, WA.
Natalie E. Rintoul, MD: 3 Department of Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
Shannon E. Hamrick, MD: 4 Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.
Rachel Chapman, MD: 5 Children’s Hospital Los Angeles and Department of Pediatrics, USC Keck School of Medicine, Los Angeles, CA.
Sarah Keene, MD: 4 Department of Pediatrics, Emory University School of Medicine, Atlanta, GA.
Ruth B. Seabrook, MD: 6 Division of Neonatology, Nationwide Children’s Hospital and Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH.
Zeenia Billimoria, MD: 2 Department of Pediatrics, Seattle Children’s Hospital and University of Washington, Seattle, WA.
Rakesh Rao, MD: 7 St. Louis Children’s Hospital and Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.
John Daniel, MD: 8 Children’s Mercy Hospitals & Clinics, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO.
John Cleary, MD: 9 Department of Pediatrics, Children’s Hospital of Orange County, Orange, CA.
Kevin Sullivan, MD: 10 Department of Pediatrics, Nemours Children’s Hospital Delaware, Wilmington, DE.
Brian Gray, MD: 12 Department of Surgery, Riley Hospital for Children and Indiana University, Indianapolis, IN.
Mark Weems, MD: 13 Department of Pediatrics, Le Bonheur Children’s Hospital and University of Tennessee, Memphis, TN.
Daniel R. Dirnberger, MD: 10 Department of Pediatrics, Nemours Children’s Hospital Delaware, Wilmington, DE.
for the CHNC ECMO Focus Group

DOI: https://doi.org/10.1097/CCE.0000000000000779
Journal volume & issue: Vol. 4, no. 11
p. e0779

Abstract

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OBJECTIVES:. To describe ventilation strategies used during extracorporeal membrane oxygenation (ECMO) for neonatal respiratory failure among level IV neonatal ICUs (NICUs). DESIGN:. Cross-sectional electronic survey. SETTING:. Email-based Research Electronic Data Capture survey. PATIENTS:. Neonates undergoing ECMO for respiratory failure at level IV NICUs. INTERVENTIONS:. A 40-question survey was sent to site sponsors of regional referral neonatal ECMO centers participating in the Children’s Hospitals Neonatal Consortium. Reminder emails were sent at 2- and 4-week intervals. MEASUREMENTS AND MAIN RESULTS:. Twenty ECMO centers responded to the survey. Most primarily use venoarterial ECMO (65%); this percentage is higher (90%) for congenital diaphragmatic hernia. Sixty-five percent reported following protocol-based guidelines, with neonatologists primarily responsible for ventilator management (80%). The primary mode of ventilation was pressure control (90%), with synchronized intermittent mechanical ventilation (SIMV) comprising 80%. Common settings included peak inspiratory pressure (PIP) of 16–20 cm H2O (55%), positive end-expiratory pressure (PEEP) of 9–10 cm H2O (40%), I-time 0.5 seconds (55%), rate of 10–15 (60%), and Fio2 22–30% (65%). A minority of sites use high-frequency ventilation (HFV) as the primary mode (5%). During ECMO, 55% of sites target some degree of lung aeration to avoid complete atelectasis. Fifty-five percent discontinue inhaled nitric oxide (iNO) during ECMO, while 60% use iNO when trialing off ECMO. Nonventilator practices to facilitate decannulation include bronchoscopy (50%), exogenous surfactant (25%), and noninhaled pulmonary vasodilators (50%). Common ventilator thresholds for decannulation include PEEP of 6–7 (45%), PIP of 21–25 (55%), and tidal volume 5–5.9 mL/kg (50%). CONCLUSIONS:. The majority of level IV NICUs follow internal protocols for ventilator management during neonatal respiratory ECMO, and neonatologists primarily direct management in the NICU. While most centers use pressure-controlled SIMV, there is considerable variability in the range of settings used, with few centers using HFV primarily. Future studies should focus on identifying respiratory management practices that improve outcomes for neonatal ECMO patients.

Published in Critical Care Explorations

ISSN: 2639-8028 (Online)
Publisher: Wolters Kluwer
Country of publisher: United States
LCC subjects: Medicine: Internal medicine: Medical emergencies. Critical care. Intensive care. First aid
Website: https://journals.lww.com/ccejournal/pages/default.aspx

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