Early veno-venous Extra Corporeal Membrane Oxygenation with prone positioning in the treatment of severe Acute Respiratory Distress syndrome in a pediatric patient: a case report
Keywords:ARDS, Conventional ventilation, ECMO, Hypoxemia, Positive end expiaratory pressure, Prone positioning
Aim of the study was to discuss effectiveness and outcome of Extra Corporeal Membrane Oxygenation (ECMO) therapy with prone positioning while on ECMO in a child with severe Acute Respiratory Distress Syndrome (ARDS). Veno-venous ECMO (VV-ECMO) and prone position on ECMO are relatively newer modalities of treatment in severe ARDS in pediatric age group and to our experience very few cases has been reported in paediatric age group. A 5 year old male child presented with fever with respiratory distress. He deteriorated in next 48 hrs leading to severe hypoxemia with ARDS following which he was put on conventional ventilation. In view of worsening critical lung parameters, veno-venous ECMO was initiated. Child had persistent hypoxemia inspite on high positive end expiaratory pressure (PEEP), adequate flow and adequate Post oxygenator PO2. Recirculation and other possible causes were excluded. Prone positioning (PP) was done for 8 hrs a day with chest physiotherapy while on ECMO. Patient showed considerable improvement in next few days and ECMO was weaned on day 7 and child was discharged on day 16 with good lung recovery. Although studies on VV-ECMO with PP has proven effectiveness in severe ARDS in adult population, overall studies in paediatric ARDS are very limited. Prone positioning on ECMO may decrease duration of ECMO support. Prone positioning on VV ECMO is safe and can be considered in Persistent hypoxemia with poor respiratory compliance.
Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med. 1994;149(3 Pt 1):818-824.
ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun 20;307(23):2526-33.
Anderson MR. Update on Pediatric Acute Respiratory Distress Syndrome. Resp Care. March 2003;48(3):261-278.
Gattinoni L, Bombino M, Pelosi P, Lissoni A, Pesenti A, Fumagalli R, et al. Lung structure and function in different stages of severe adult respiratory distress syndrome. JAMA. 1994 Jun 8;271(22):1772-9.
The Pediatric Acute Lung Injury Consensus Conference Group (2015). Pediatric Acute Respiratory Distress Syndrome: Consensus Recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med. 2015;16(5),428-439.
D Ng, W Klein, R Tran, D Riddle-Branske, PJ Luna, HB Nguyen. Combination therapy with high-frequency oscillatory ventilation, neuromuscular blockade, inhaled nitric oxide and prone position in acute respiratory distress syndrome with refractory hypoxaemia. Anaesth intensive care. 2012;40(5):898-9.
Davis SL, Furman DP, Costarino AT Jr. Adult respiratory distress syndrome in children: associated disease, clinical course, and predictors of death. J Pediatr. 1993 Jul;123(1):35-45.
Conrad SA, Grier LR, Scott LK, Green R, Jordan M. Percutaneous cannulation for extracorporeal membrane oxygenation by intensivists: a retrospective single-institution case series. Crit Care Med. 2015 May;43(5):1010-5.
Iwahashi H, Yuri K, Nosé Y. Development of the oxygenator: past, present, and future. J Artif Organs. 2004;7(3):111-20.
Rivera RA, Butt W, Shann F. Predictors of mortality in children with respiratory failure: possible indications for ECMO. Anaesth Intensive Care. 1990 Aug;18(3):385-9.
L'Her E, Renault A, Oger E, Robaux MA, Boles JM. A prospective survey of early 12-h prone positioning effects in patients with the acute respiratory distress syndrome. Intensive Care Med. 2002 May;28(5):570-5.
Guervilly C, Hraiech S, Gariboldi V, Xeridat F, Dizier S, Toesca R, et al. Prone positioning during veno-venous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome in adults. Minerva Anestesiol. 2014 Mar;80(3):307-13.