Utilization of ECMO with fiberoptic bronchoscopy for pediatric patients with lethal pulmonary hemorrhage unresponsive to conventional mechanical ventilation

Yingfu Chen ^* Siwei Lu Yuelin Sun Yueqiang Fu Jing Li Chengjun Liu

• Intensive Care Unit,Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders. Chongqing Key Laboratory of Child Neurodevelopment and Cognitive Disorders,, Intensive Care Unit, Pediatrics, Chongqing, China

Objective: To evaluate the safety and efficacy of ECMO combined with fiberoptic bronchoscopy in children with life threatening pulmonary hemorrhage that does not respond to conventional mechanical ventilation.Methods: From October 2019 to June 2022, four pediatric patients with life threatening pulmonary hemorrhage requiring ECMO support were admitted to our hospital. Based on their weight and vascular conditions, either VA-ECMO or VV-ECMO was selected. The anticoagulation strategy was tailored, and fiberoptic bronchoscopy was performed to assess airway bleeding and remove blood clots.Results: The study involved four patients. Case 1 sustained injuries from a traffic accident, Case 2 experienced combined injuries from a high fall, Case 3 had pulmonary vascular malformation, and Case 4 presented with anti-neutrophil cytoplasmic antibody-associated vasculitis. Case 1 underwent VA-ECMO with carotid artery and vein cannulation, whereas the other patients received VV-ECMO with jugular-femoral vein cannulation. During cannulation, heparin was administered at 0.5 mg/kg. Protamine was subsequently used to neutralize heparin based on the bleeding situation. Anticoagulation was initiated 24 h after ECMO commencement in Cases 1, 2, and 4, maintaining an activated clotting time (ACT) of 160-180 s. In Case 3, active bleeding was observed in the tracheal tube post-ECMO initiation. Protamine was administered to reverse the effects of heparin, and anticoagulation was withheld for the first 72 h. After a second interventional embolization of the vascular malformations, the active bleeding ceased. Two fiberoptic bronchoscopies revealed no further bleeding, and anticoagulation was initiated at 5 U/kg/h to maintain an ACT of 160 s. Heparin was paused 1 h before each fiberoptic bronchoscopy and resumed afterward. During ECMO, all patients successfully underwent fiberoptic bronchoscopy. Cases 2 and 3 required three and six procedures, respectively. Substantial thrombi were removed from the airways of Cases 2 and 3. All patients survived, and they were discharged without complications related to ECMO or fiberoptic bronchoscopy.Conclusion: For children with life-threatening pulmonary hemorrhage that did not respond to conventional mechanical ventilation, the combination of ECMO and fiberoptic bronchoscopy represents a promising therapeutic option. this combined approach is both safe and effective, significantly improving clinical outcomes in pediatric patients with life threatening pulmonary hemorrhage.