Extracorporeal Membrane Oxygenation (ECMO) for Hypoxemic Respiratory Failure

secondary to human Metapneumovirus (hMPV) Bronchiolitis

Renee Mintak, Kevin Ramsay, Doug Salt, Dr Avash J. Singh, Dr Arthur Cogswell
ECLS Program, Childrens & Womens Health Centre of BC and Department of Pediatrics, UBC, Vancouver, BC, Canada

Most of the respiratory viruses were identified during the 1950-1960s. It was 35 years after the discovery
of coronaviruses, that a new major respiratory pathogen infecting humans was discovered by van den Hoogen et al
in the Netherlands in 2001, and based on virological data, sequence homology and gene constellation, this new
virus, belonging to the Paramyxoviridae family and Metapneumovirus genus, was named hMPV. Since then several
research groups have identified it to infect both children and adults. The occurrence of hMPV infections has been
documented to range from 1.3 - 25.5%, depending on the population studied. Also hMPV, like RSV predominantly
infects children 12 months of age. Seroprevalence data has demonstrated 100% seropositivity by 5 years of age.
Clinically and cytopathologically, infection with hMPV resembles infection with RSV. In young children,
the most common clinical symptoms of hMPV infections are fever, rhinorrhoea, wheezing, tachypnea and cough,
consistent with a common cold, bronchiolitis and/or pneumonia syndrome. Data support hMPV as the causative
agent of up to 10% of children with acute respiratory infection. It is also capable of inducing a severe illness in high
risk patients and can cause clinically important re-infection in late childhood and in adults as well.
CASE STUDY:
An ex-extremely low birth weight male, corrected 5 weeks, presented to our hospital in March 2003 with
acute respiratory distress. Past medical history was significant for extreme prematurity (27 weeks AGA), neonatal
respiratory distress syndrome requiring 10 days of assisted IPPV and 8 days of nasal-CPAP. RSV
immunoprophylaxis (Palivizumab) was given at 2 and 3 months of age. He had also received his 2 month
immunizations. The infant was discharged home at 3 months postnatal age. He had been at home for five weeks
prior to his current presentation to the hospital.
He presented with cyanosis, bradycardia, and apneas, which was preceded by 3 days of rhinorrhoea. This
necessitated emergency intubation and IPPV, IV sedation and paralysis. Sepsis evaluation included cultures of
blood, urine and nasopharyngeal & endotracheal tube aspirate specimens.
His clinical condition continued to deteriorate with worsening of his respiratory failure, with CO 2 retention
(paCO2 80+ mmHg) and hypoxemia (Oxygen Index >40). Chest radiographs demonstrated extensive bilateral
consolidations with loss of aeration. By the 4 th day of admission, therapies had been escalated to include IV
steroids. Other ventilatory modalities including high frequency oscillatory ventilation and 20 ppm inhaled nitric
oxide with no demonstrable beneficial effects. The decision to commence ECMO was made.
A 15Fr double-lumen veno-venous cannula (Origen ) was inserted via the R. internal jugular vein into the
right atrium and an 8Fr cephalad venous drainage catheter was also placed. The ECMO circuit consisted of a
centrifugal pump (Biomedicus, BP 50), circuit and a silicone membrane artificial lung (Avecor 1500). Total
ECMO flows stabilized at 460 mL/min (120mL/kg/min), with cephalad flows of 160-175mL/min, venous line
negative pressures of -12 to -17cmH2O, membrane sweep gas flows of 400-550 mL/min and FiO 2 of 0.60-0.70 to
achieve clinical targets of: paCO2 40-50 mmHg, SpO2 >85%.
Biohead changes were performed at ECMO hours of 39, 82 and 132 based on rising plasma free
hemoglobin concentrations, as per protocol. The ECMO circuit was changed at hour 184, as per protocol.
3 days into the ECMO run, the etiology for bronchiolitis was confirmed by PCR on nasopharyngeal wash
specimen as human Metapneumovirus and reported negative for RSV, mycoplasma, Chlamydia, pertussis,
influenzas A & B and adenovirus.
The initial patient recovery was minimal, with the first sign of an improvement in oxygenation noted on
day 4 of ECMO, when the O2 challenge demonstrated an improvement in paO2 from 52 to 75 mmHg. A trial to
wean off ECMO on day 7 was aborted due to the need for high assisted ventilation. The patient was successfully
weaned and de-cannulated after 9 days of VV+V ECMO support. He required an additional 5 days of assisted IPPV,
2 days of nasal-CPAP and 7 days of low-flow supplemental O 2 post ECMO. The patient was discharged home, 30
days after admission.
DISCUSSION:
We report the first case of hMPV bronchiolitis in an infant, successfully treated with VV+V ECMO. We
suggest that ECMO support should be considered in infants presenting with respiratory failure of unknown etiology.
We also recommend that if possible, past cases of ARDS in infants treated with ECMO be reviewed from the ELSO
Registry, and if possible to reanalyze the nasopharyngeal specimens for hMPV as an etiologic agent.
Renee Mintak, ECLS Team Leader
B.C. Childrens Hospital, Room 1J8, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada
Tel: 604 875 2345 extn 6598
rmintak@cw.bc.ca