Severe respiratory failure in neonates: Mortality and morbidity rates and neurodevelopmental outcomes☆,☆☆,★

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Abstract

Objective: To compare the survival, neurodevelopmental, and health outcomes of children with severe respiratory illness treated with and without extracorporeal membrane oxygenation (ECMO). Design: Prospective collection of clinical and demographic data of all neonates reaching illness severity criteria, with follow-up at 8 and 20 months of age. Patients were assigned to treatment by the attending physician. Patients: Consecutive sample of 74 neonates during a 24-month period with an alveolar-to-arterial gradient exceeding 620 for 8 or more hours. Results: Eighteen (69%) of 26 neonates treated with conventional therapy survived to 20 months, in comparison with 43 (90%) of 48 neonates treated with ECMO. The conventionally treated group had significantly more chronic lung disease, longer duration of oxygen therapy, more chronic reactive airway disease, and more rehospitalizations than those treated with ECMO. Hospital charges were similar in the two groups. Macrocephaly was noted in 24% of those treated with ECMO and in none of the conventional group. Of those completing evaluation, 4 (24%) of 17 conventionally treated survivors and 20 (26%) of 38 ECMO-treated survivors had neurodevelopmental impairment. Conclusion: Survivors of severe neonatal respiratory illness have significant pulmonary and neurodevelopmental impairment, regardless of the treatment used. Neonates treated with ECMO had neurodevelopmental outcomes similar to those of patients treated conventionally, but better pulmonary outcomes. (J PEDIATR 1994;125:104-10)

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METHODS

The study population was drawn from a cohort of 889 neonates with birth weight exceeding 2.0 kg and gestational age exceeding 34 weeks who were admitted to the neonatal intensive care unit at Rainbow Babies and Childrens Hospital, Cleveland, Ohio, between July 1987 and June 1989. All patients who met weight and gestational age criteria were tracked prospectively on admission to the neonatal intensive care unit. Patients with congenital diaphragmatic hernia and cardiac malformations were

Description of population and survival rate

The study population included 74 neonates with severe respiratory illness who had an P(a - a)o2 exceeding 620 for 8 hours, of whom 26 were treated with conventional therapy and 48 with ECMO. The reasons for continuing conventional therapy rather than initiating ECMO treatment included an improvement with additional treatment, suspected neurologic injury, parental refusal, hemorrhage contraindicating ECMO, and death before ECMO (Table I). Patients in whom ECMO was thought to be contraindicated

DISCUSSION

Treatment of respiratory failure in the term and near-term neonate is far from uniform, and is in rapid evolution. Evaluation of the effectiveness of new techniques depends on the knowledge of the base rates of impairment in the entire spectrum of newborn infants with the underlying condition. This information has not been collected systematically in term neonates with severe respiratory illness. Our study reports the overall outcome and neurodevelopmental status of a cohort of survivors of

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From the Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio

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Reprint requests: Michele C. Walsh-Sukys, MD, Department of Pediatrics, Rainbow Babies and Children's Hospital, 2074 Abington Rd., Cleveland, OH 44106.

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0022-3476/94/$3.00 + 0 9/23/54947

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