Ventilator management of infants before extracorporeal membrane oxygenation

The aim of this project was to review the course of infants referred for consideration of extracorporeal membrane oxygenation (ECMO) to identify maximal ventilator settings that, when exceeded, did not provide clinical benefit to the patient. These settings might then be used in defining failure of conventional mechanical ventilation. We reviewed referral records and hospital charts of all infants treated for severe respiratory failure due to meconium aspiration syndrome during the 52.5 month period from March 15, 1985, to August 1, 1989. At an inspiratory pressure >35 cm H₂O, 75% (43/57) of patients eventually required ECMO, and 28% (4/14) of the infants who did not receive ECMO died. When the inspiratory pressure was ≤40 cm H₂O, 39/49 patients required ECMO, and 30% (3/10) of those not treated with ECMO died. Once the inspiratory pressure was >45 cm H₂O, 91% (29/32) of patients required ECMO, and only one third of those not treated with ECMO survived. Although the limitations for conventional therapy suggested in this paper may be helpful to clinicians, each center needs to establish guidelines for maximal conventional ventilator support. If these guidelines are clearly defined, alternative methods of therapy can be used once these criteria are achieved.