Bridging the Gap Between Intensivists and Primary Care Clinicians in Extracorporeal Membrane Oxygenation for Respiratory Failure in Children: A Review

Abstract

Importance: Extracorporeal membrane oxygenation (ECMO) is a form of advanced life support that may be used in children with refractory respiratory or cardiac failure. While it is required infrequently, in the US, ECMO is used to support childhood respiratory failure as often as children receive kidney or heart transplants. ECMO is complex, resource intensive, and potentially lifesaving, but it is also associated with risks of short-term complications and long-term adverse effects, most importantly with neurodevelopmental outcomes that are relevant to all pediatric clinicians, even those remote from the child's critical illness.

Observations: The 2009 influenza A(H1N1) pandemic, along with randomized clinical trials of adult respiratory ECMO support and conventional management, have catalyzed sustained growth in the use of ECMO. The adult trials built on earlier neonatal ECMO randomized clinical trials that demonstrated improved survival in severe perinatal lung disease. For children outside of the neonatal period, there appear to have been no respiratory ECMO clinical trials. Applying evidence from adult respiratory failure or perinatal lung disease to children outside the neonatal period has important potential pitfalls. For these children, the underlying diseases and risks of ECMO are different. Despite these differences, both neonates and older children are at risk of neurologic complications, such as intracranial hemorrhage, ischemic stroke, and seizures, and those complications may contribute to adverse neurodevelopmental outcomes. Without specific screening, subtle neurodevelopmental impairments may be missed, but when they are identified, children have the opportunity to receive therapy to optimize long-term development.

Conclusions and relevance: All pediatric clinicians should be aware not only of the potential benefits and complications of ECMO but also that survivors need effective screening, support, and follow-up.

Figure 1.

Anatomy and physiology of pediatric extracorporeal membrane oxygenation (ECMO). The blood pump withdraws venous blood from the child and propels through the ECMO circuit. The sweep gas flows from an oxygen-air blender to the membrane lung. In the membrane lung, blood surrounds hollow fibers as sweep gas is propelled through the fibers, allowing gas exchange with the blood. At top right, venovenous ECMO using a dual-lumen cannula; in this case, blood is withdrawn from the superior and inferior vena cava and reinfused into the right atrium. At bottom right, venoarterial ECMO using 2 cannulae; in this case, blood is withdrawn from the superior vena cava or right atrium and reinfused into the common carotid or brachoecepahlic artery. FDO indicates delivered fractional oxygen percentage.

Figure 2.

Proportion of children with carotid artery cannulation for respiratory extracorporeal membrane oxygenation (ECMO). Data are based on an Extracorporeal Life Support Organization Registry report (January 2020). Neonates are those aged 0 to 28 days; pediatric patients are those aged 29 days to 17 years. All children includes both age ranges.

Figure 3.

Complication rates reported in children supported with respiratory extracorporeal membrane oxygenation Neonates are aged 0 to 28 days; pediatric patients are 29 days to 17 years old. CPR indicates cardiopulmonary resuscitation. ^a Complication rates are reported from December 2012 to September 2014 among 151 neonates and 86 pediatric cases. ^b Complication rates are based on Extracorporeal Life Support Organization reports from January 2014 to December 2018 among 4162 neonates and 3136 pediatric cases.