How does the changing profile of infants who are referred for extracorporeal membrane oxygenation affect their overall respiratory outcome?

Extracorporeal Life Support Organization (ELSO) Guidelines for Follow-up After Neonatal and Pediatric Extracorporeal Membrane Oxygenation

Neonates and children who have survived critical illness severe enough to require extracorporeal membrane oxygenation (ECMO) are at risk for neurologic insults, neurodevelopmental delays, worsening of underlying medical conditions, and development of new medical comorbidities. Structured neurodevelopmental follow-up is recommended for early identification and prompt interventions of any neurodevelopmental delays. Even children who initially survive this critical illness without new medical or neurologic deficits remain at risk of developing new morbidities/delays at least through adolescence, highlighting the importance of structured follow-up by personnel knowledgeable in the sequelae of critical illness and ECMO. Structured follow-up should be multifaceted, beginning predischarge and continuing as a coordinated effort after discharge through adolescence. Predischarge efforts should consist of medical and neurologic evaluations, family education, and co-ordination of long-term ECMO care. After discharge, programs should recommend a compilation of pediatric care, disease-specific care for underlying or acquired conditions, structured ECMO/neurodevelopmental care including school performance, parental education, and support. Institutionally, regionally, and internationally available resources will impact the design of individual center's follow-up program. Additionally, neurodevelopmental testing will need to be culturally and lingually appropriate for centers' populations. Thus, ECMO centers should adapt follow-up program to their specific populations and resources with the predischarge and postdischarge components described here.

Long-term outcome of children treated with neonatal extracorporeal membrane oxygenation: increasing problems with increasing age

As more and more critically ill neonates survive, it becomes important to evaluate long-term morbidity. This review aims to provide an up-to-date overview of medical and neurodevelopmental outcomes in children who as neonates received treatment with extracorporeal membrane oxygenation (ECMO). Most patients-except those with congenital diaphragmatic hernia-have normal lung function and normal growth at older age. Maximal exercise capacity is below normal and seems to deteriorate over time in the CDH population. Gross motor function problems have been reported until school age. Although mental development is usually favorable within the first years and cognition is normal at school age, many children experience problems with working speed, spatial ability tasks, and memory. In conclusion, children who survived neonatal treatment with ECMO often encounter neurodevelopmental problems at school age. Long-term follow-up is needed to recognize problems early and to offer appropriate intervention.

Prospective longitudinal evaluation of lung function during the first year of life after extracorporeal membrane oxygenation

OBJECTIVE

To collect longitudinal data on lung function in the first year of life after extracorporeal membrane oxygenation and to evaluate relationships between lung function and perinatal factors. Longitudinal data on lung function in the first year of life after extracorporeal membrane oxygenation are lacking.

DESIGN

Prospective longitudinal cohort study.

SETTING

Outpatient clinic of a tertiary level pediatric hospital.

PATIENTS

The cohort consisted of 64 infants; 33 received extracorporeal membrane oxygenation for meconium aspiration syndrome, 14 for congenital diaphragmatic hernia, four for sepsis, six for persistent pulmonary hypertension of the neonate, and seven for respiratory distress syndrome of infancy. Evaluation was at 6 mos and 12 mos; 39 infants were evaluated at both time points .

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Functional residual capacity and forced expiratory flow at functional residual capacity were measured and expressed as z score. Mean (sem) functional residual capacities in z score were 0.0 (0.2) and 0.2 (0.2) at 6 mos and 12 mos, respectively. Mean (sem) forced expiratory flow was significantly below average (z score = 0) (p < .001) at 6 mos and 12 mos: -1.1 (0.1) and -1.2 (0.1), respectively. At 12 mos, infants with diaphragmatic hernia had a functional residual capacity significantly above normal: mean (sem) z score = 1.2 (0.5).

CONCLUSIONS

Infants treated with extracorporeal membrane oxygenation have normal lung volumes and stable forced expiratory flows within normal range, although below average, within the first year of life. There is reason to believe, therefore, that extracorporeal membrane oxygenation either ameliorates the harmful effects of mechanical ventilation or somehow preserves lung function in the very ill neonate.

Respiratory function during infancy in survivors of the INNOVO trial

RATIONALE

Despite encouraging reports suggesting that inhaled nitric oxide (iNO) appear to improve outcome in hypoxemic term and near term infants by improving oxygenation and reducing need for ECMO, the long-term benefits of iNO remain unclear. This study aimed to compare lung function at approximately 1 year in infants who were and were not randomly allocated to iNO as part of their neonatal management for severe respiratory failure at birth. Furthermore, results were compared to lung function of healthy infants.

METHODS

Maximal expiratory flow at functional residual capacity (V'maxFRC) was measured at approximately 1 year of age (corrected for any prematurity) in survivors of the INNOVO trial. Results were expressed as Z-scores, adjusted for sex and body size, based on data from healthy controls using identical techniques.

RESULTS

Technically satisfactory results were obtained in 30 infants (53% < 34 weeks gestation), 19 of whom were randomized to receive iNO V'maxFRC. Z-score was significantly reduced in infants with prior respiratory failure, whether or not they had been allocated to iNO (mean (SD) Z-score: -2.0 (1.2) and -2.6 (1.1), respectively, 95% CI difference; iNO vs. no iNO: -0.3; 1.6, P = 0.2). There was significant respiratory morbidity in both groups during the first year of life.

CONCLUSIONS

These results suggest that airway function remains reduced at 1 year of age following severe respiratory failure at birth, whether or not iNO is administered.