TREATMENT OF SEVERE NONNEONATAL ARDS CHILDREN WITH SURFACTANT AND NITRIC-OXIDE IN A PRE-ECMO-SITUATION

The use of exogenous surfactant and nitric oxide in neonates has reduc ed the number of infants requiring ECMO. The purpose of this study was to demonstrate whether these two therapeutic options might reduce the number of over 28 days old children with severe ARDS requiring ECMO, without reducing changes of survival and morbidity. Over a 30 month pe riod all non-neonatal ARDS patients transferred to our institution for ECMO evaluation were treated based on a study-algorithm. If they did not fulfill ''fast entry criteria'' (paO(2) < 40 for more than 3 hrs.) we first tried different ventilation, vasodilatation, and hemodynamic strategies for max. 4 hrs. (inv. I/E ratio, HFOV, epoprostenol, high doses norepinephrine. If the OI did not decrease by < 10, 30-280 mg na tural surfactant or 1-20 ppm nitric oxide were treatment options depen ding on the degree of pulmonary hypertension measured by echocardiogra phy and by mixed venous saturation measurements. It was possible to us e NO and surfactant sequentially. The patients had different etiologie s of ARDS as near drowning, pneumonia, immunosuppression, and sepsis. If their OI did not decrease by 10 in 8 hrs. ECMO was installed. Ninet een patients were evaluated, 6 improved with conventional therapy, the ir OI decreased without a relapse (mean OI at begin of the study: 38). Six patients improved with surfactant therapy alone (mean OI: 54), 4 patients improved after surfactant and sequential NO-treatment. 3 pati ents were initially treated with NO, 1 sequentially with surfactant. O ne patient did not show any benefit from NO or surfactant and was put on ECMO. Three patients died (withdrawal of life support because of se vere brain damage caused by the underlying disease). We could not obse rve any respiratory related failure. No patient had to be discharged o n oxygen. A sophisticated treatment algorithm integrating different mo dern ARDS treatment options can reduce the number of patients requirin g ECMO. We speculate however that these options can only be used effec tively in centers involved in ARDS treatment quite frequently and that these centers have to provide ECMO as one of their therapeutic tools.