Risk of need for extracorporeal membrane oxygenation support in neonates with congenital diaphragmatic hernia treated with inhaled nitric oxide.

BACKGROUND

Congenital diaphragmatic hernia (CDH) is often associated with severe pulmonary hypoplasia resulting in hypoxemic respiratory failure unresponsive to advanced medical management including the use of inhaled nitric oxide (iNO). For these patients, extracorporeal membrane oxygenation (ECMO) serves as the last potentially effective treatment choice. Since the efficacy of iNO in this patient population is not known and since most neonatal intensive care units using iNO for the treatment of these critically ill neonates do not provide ECMO, the ability to more accurately predict which patient is at risk for failing medical management with iNO and requires a timely transfer to an ECMO center can be life saving. Therefore, in this study, we sought to determine the risk factors for the need for ECMO in a cohort of 27 neonates with isolated left CDH and hypoxemic respiratory failure treated with iNO.

STUDY

DESIGN

In this retrospective study, 27 patients with left CDH were identified during a 2-year period. During the study period, strict clinical guidelines had been used to standardize iNO therapy, to provide adequate lung inflation and cardiovascular support, and to recognize treatment failures and the need for ECMO. Logistic regression analysis was used to study the relationship between the need for ECMO and a set of suspected risk factors.

RESULTS

When subjected to logistic regression analysis, only the presence of a pneumothorax remained significantly associated with the need for ECMO (OR=22; 95% CI=2.18 to 222), while none of the other variables examined such as mean airway pressure, FiO2, PaO2, or PaCO2 were predictors for the need of ECMO after 6 hours of treatment with iNO.

CONCLUSION

These data indicate that a prompt transfer to an ECMO center should be initiated for hypoxemic patients with CDH receiving medical management with iNO if they develop an air leak syndrome.