Abstract
We report on 50 term and near-term neonates (birth weight > 1800 g, gestational age > 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<45 mm Hg when ventilated with peak inspiratory pressure >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<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<0.05), had higher Apgar scores and were less hypoxaemic before HFOV (paO2 36.6 mm Hg vs 28.8 mm Hg,P<0.01); during HFOV there was a significant rise in paO2 (> 150 mm Hg;P<0.001) and a fall in pCO2 to 21.6 mm Hg (P<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. Mean duration of HFOV was 37.8 h vs 84.9 h of ECMO. PPHN could be overcome in 88% of the HFOV-treated and in 76% of the ECMO-treated infants; overall survival rate was 74% (predicted probability of survival using maximum conventional treatment <10%). There were no significant differences between HFOV/ECMO groups with regard to duration of ventilation following HFOV/ECMO, total time in hospital, rate of bronchopulmonary dysplasia and neurological complications (intracranial haemorrhage, brain infarction). Among the survivors, the rate of mentally handicapped children was equal in both groups (overall 18.9%). Our analysis shows that about 50% of neonates with PPHN who fail to respond to conventional ventilatory support and maximum treatment can be treated successfully with HFOV, thus avoiding ECMO. By applying both forms of therapy, the survival rate of infants with severe PPHN can be increased from an estimated rate of <10% up to 80%.
Article PDF
Similar content being viewed by others
Abbreviations
- AaDO2 :
-
alveolar-arterial O2 difference (=76047−pCO2−paO2)
- BPD:
-
bronchopulmonary dysplasia
- CDH:
-
congenital diaphragmatic hernia
- ECMO:
-
extracorporeal membrane oxygenation
- HFOV:
-
high frequency oscillatory ventilation
- ICH:
-
intracranial haemorrhage
- MAP:
-
mean airway pressure
- NICU:
-
neonatal intensive care unit
- PEEP:
-
positive end-expiratory pressure (cm H2O)
- PIP:
-
peak inspiratory pressure (cm H2O)
- PPHN:
-
persistent pulmonary hypertension of the newborn
References
Bartlett RH, Gazzaniga AB, Jefferies MR, Huxtable RF, Haiduc NJ, Fong SW (1976) Extracorporeal membrane oxygenation (ECMO), cardiopulmonary support in infancy. Trans Am Soc Artif Organs 22:80–93
Bartlett RH, Roloff DW, Cornell RG, Andrews AF, Dillon PW, Zwischenberger JB (1985) Extracorporeal circulation in neonatal respiratory failure: a prospective randomized trial. Pediatrics 76:479–487
Blum-Hoffmann E, Kopotic RJ, Mannino FL (1988) High frequency oscillatory ventilation combined with intermittent mandatory ventilation in critically ill neonates: 3 years of experience. Eur J Pediatr 147:392–398
Bui KC, Cornish JD (1990) Innovative therapies for neonatal respiratory failure: high-frequency ventilation and extracorporeal membrane oxygenation. Sem Respir Med 11:127–139
Carter JM, Gerstmann DR, Clark RH, Snyder G, Cornish JD, Null DM, Lemos RA de (1990) Extracorporeal membrane oxygenation for the treatment of acute neonatal respiratory failure. Pediatrics 85:159–164
Chang HK, Harf A (1984) High-frequency ventilation: a review. Respir Physiol 57:135–152
Clark RH, Wiswell TE, Null DM, Lemos RA de, Coalson JJ (1987) Tracheal and bronchial injury in high-frequency oscillatory ventilation compared with conventional positive pressure ventilation. J Pediatr 11:114–118
Cornish JD, Gerstmann DR, Clark RH, Carter JM, Null DM, Lemos RA de (1987) Extracorporeal membrane oxygenation and high frequency oscillatory ventilation: potential therapeutical relationships. Crit Care Med 15:831–834
Crombleholme TM, Adzick NS, Lorimier AA de, Longaker MT, Harrison MR, Charlton VE (1990) Carotid artery reconstruction following extracorporeal membrane oxygenation. Am J Dis Child 144:872–874
Dworetz AR, Moya FR, Sabo B, Gladstone I, Ross I (1990) Survival of infants with persistent pulmonary hypertension without extracorporeal membrane oxygenation. Pediatrics 85:1–6
Glass P, Miller M, Short B (1989) Morbidity for survivors of extracorporeal membrane oxygenation: neurodevelopmental outcome at 1 year of age. Pediatrics 83:72–78
Hofkosh D, Thompson AE, Nozza RJ, Kemp SS, Bowen AD, Feldman HM (1991) Ten years of extracorporeal membrane oxygenation: neurodevelopmental outcome. Pediatrics 87:549–555
Kachel W, Eisen R, Kempf T (1987) Quantitative Prognose der Mortalität beim beatmeten Neugeborenen. Z Geburtshilfe Perinatol 191:34–39
Kachel W, Arnold D, Rettwitz W, Lasch P, Brands W (1987) Extrakorporale Membranoxygenierung (ECMO) Monatsschr Kinderheilkd 135:735–741
Kohelet D, Perlman M, Kirpalani G, Hanna G, Koren G (1988) High-frequency oscillation in the rescue of infants with persistent pulmonary hypertension. Crit Care Med 16:510–516
Marchak BE, Thomson WK, Duffy P, Miyaki T, Bryan MH, Bryan AC, Froese AB (1981) Treatment of RDS by high-frequency oscillatory ventilation. A preliminary report. J. Pediatr 99:287–292
Meinert C (1990) Extracorporeal membrane oxygenator trials. Pediatrics 85:365–366
O'Rourke PP, Crone RK, Vacanti JP, Ware JH, Lillehei CW, Parad RB, Epstein MF (1989) Extracorporeal membrane oxygenation and conventional medical therapy for neonates with persistent pulmonary hypertension of the newborn. Pediatrics 84:957–963
Raju TM, Kim SY, Meller JL, Srinivasan G, Chai V, Reyes H (1989) Circle of Willis blood velocity and flow direction after common carotid artery ligation for neonatal extracorporeal membrane oxygenation. Pediatrics 83:343–347
Schumacher RE, Palmer TW, Roloff DW, Laclaire PA, Bartlett RH (1991) Follow-up of infants treated with extracorporeal membrane oxygenation for newborn respiratory failure. Pediatrics 87:451–457
Short BL, Miller MK, Anderson KD (1987) Extracorporeal membrane oxygenation in the management of respiratory failure in the newborn. Clin Perinatol 14:737–747
Southgate W, Howell CG, Kanto WP (1990) Need for and impact on neonatal mortality of extracorporeal membrane oxygenation in infants of greater than 2500 gram birth weight. Pediatrics 86:71–74
Stolar C, Snedecor SM, Bartlett RH (1991) Extracorporeal membrane oxygenation and neonatal respiratory failure: experience from the extracorporeal life support organization. J Pediatr Surg 26:563–571
Vaucher YE, Dudell G, Cornish JD, Gist K (1990) Outcome in ECMO eligible neonates treated with ECMO, HFOV or conventional ventilation. Pediatr Res 27:260A
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Varnholt, V., Lasch, P., Suske, G. et al. High frequency oscillatory ventilation and extracorporeal membrane oxygenation in severe persistent pulmonary hypertension of the newborn. Eur J Pediatr 151, 769–774 (1992). https://doi.org/10.1007/BF01959088
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF01959088