Extracorporeal Membrane Oxygenation for Acute Pediatric Respiratory Failure

This article is made available for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.The use of extracorporeal membrane oxygenation (ECMO) to support children with acute respiratory failure has steadily increased over the past several decades, with major advancements having been made in the care of these children. There are, however, many controversies regarding indications for initiating ECMO in this setting and the appropriate management strategies thereafter. Broad indications for ECMO include hypoxia, hypercarbia, and severe air leak syndrome, with hypoxia being the most common. There are many disease-specific considerations when evaluating children for ECMO, but there are currently very few, if any, absolute contraindications. Venovenous rather than veno-arterial ECMO cannulation is the preferred configuration for ECMO support of acute respiratory failure due to its superior side-effect profile. The approach to lung management on ECMO is variable and should be individualized to the patient, with the main goal of reducing the risk of VILI. ECMO is a relatively rare intervention, and there are likely a minimum number of cases per year at a given center to maintain competency. Patients who have prolonged ECMO runs (i.e., greater than 21 days) are less likely to survive, though no absolute duration of ECMO that would mandate withdrawal of ECMO support can be currently recommended

Indications for Invasive Conventional Mechanical Ventilation

The spectrum and severity of respiratory illness in the newly born has been changing over the past three decades with the introduction of antenatal steroids, improved management of the fetus during preterm labor and birth, and postnatal exogenous surfactant administration. Early pulmonary parenchymal failure requiring invasive ventilation occurs less frequently. Moderately preterm infants who received invasive mechanical ventilation in the past can often be managed nowadays with noninvasive respiratory support. There is, however, a “new generation” of surviving extremely small infants who depend on early initiation of invasive ventilation and who stay on the ventilator for extended periods of time with substantial risks for ventilator-induced lung injury. Such infants often require invasive ventilation for reasons other than surfactant deficiency. These comprise, among others, respiratory pump failure and intermittent failure of the immature respiratory rhythm generator and control of breathing. Diverse invasive mechanical ventilation strategies and modalities have been developed to better address these problems; however, evidence of their effectiveness is still scarce. Therefore, the clinician’s expertise in some of the basic invasive ventilation techniques and devices probably remains the key determinant of a successful application