A Respiratory Centre and Network Model for the Management of Severe Hypoxaemic Respiratory Failure

The development of specialist respiratory centres for the management of severe refractory hypoxaemic respiratory failure is advocated based largely on three premises: 1. High volume units have better outcomes than smaller volume units.1-4 2. The provision of extra-corporeal membrane oxygenation (ECMO) in the UK is limited and patients should be selected according to need. Those patients requiring ECMO are best recognised by intensivists working in high volume centres, either following discussion with the smaller unit or following a trial of care in the high volume centre.5 3. Only larger units have what Bob Winter refers to in his editorial in the January 2011 issue of JICS as a ‘wider range of witchcraft’6 and others may know as high frequency oscillation (HFOV), and nitric oxide (NO). These may have a role as rescue therapies before a trial of ECMO. Those arguing against such logic point to the following flaws: 1. Comparing outcome of high volume to low volume units does not equate to the introduction of a policy to transfer patients failing conventional treatment. 2. Transfer of patients is already historically contentious7,8 and a second transfer for ECMO, following an initial transfer from a small unit to a respiratory centre is even more so. 3. There is a lack of compelling evidence demonstrating benefit from ECMO, HFOV, NO, and prone ventilation. To summarise, those arguing against the respiratory centre concept point to a lack of good evidence for its implementation, and worry that the real agenda is one of centralisation of services. Those arguing for respiratory centres cite the unintended consequence in the CESAR study, demonstrating that patients transferred but not receiving ECMO had better than expected outcomes.9 The document ‘The management of severe refractory hypoxia in critical care in the UK in 2010,’5 recommends that Networks implement the policy of identifying respiratory centres. In South East Wales we have had a managed clinical network for five years (SEWCCN), covering three of the seven recently created Welsh Health Boards (Aneurin Bevan, Cwm Taf and Cardiff and Vale University Health Board). Within the three Health Boards, there are five District General Hospital (DGH) critical care units which each have between 5-8 level 3 beds, and one Teaching Hospital Unit – University Hospital of Wales (UHW) – which has 14 level 3 beds (Table 1). Early in the 2009 H1N1 influenza A pandemic, it became clear that the morbidly obese and those with chronic lung disease were at greater risk of severe respiratory failure. South East Wales, with a population of 1.4 million, has a particularly high incidence of obesity10 and chronic lung disease11 related to previous industrial lung exposure, severe chronic social deprivation, and a high prevalence of cigarette smoking. We therefore expected to be particularly vulnerable to this pandemic, and set up in 2009 what would now be recognised as a ‘Respiratory Centre’ model. A series of meetings about influenza were organised by the Network to agree a way forward based on the information about H1N1 available at that time. When it became clear that ventilators planned for use to create surge capacity were not fit for the purpose of ventilating patients with severe refractory respiratory failure, the first step the Network took was to improve equipment in all units. Following discussion with the SEWCCN, the Welsh Assembly Government agreed to fund 50% of the level 3 surge capacity ventilators as intensive care unit ventilators. The second step, based upon the published experience particularly from North America and Australasia, was to develop local protocols: in Canada,12 81% of patients (n=168) were ventilated on the first day of critical care admission. Of those that required rescue therapy for hypoxia, 28% received neuromuscular blockade, 13.7% inhaled NO, 11.9% HFOV, 4.2% ECMO, and 3% prone ventilation. In Australasia 11.6% of those mechanically ventilated (n=456) received ECMO for H1N1 Hospital Number of Surge capacity Level 3 beds identified

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