Aims The authors reviewed the pre-extracorporeal membrane oxygenation (ECMO) management of the neonates with persistent pulmonary hypertension (PPHN) with the aim to detect any deficiencies and to formulate strategies to improve practice.

Methods Retrospective review of all case notes of neonates with PPHN needing ECMO from May 2006 to July 2008 (26 months).

Results Sixty neonates (37 females and 23 male) with the diagnosis of PPHN were referred for ECMO in the study period. Mean age of referral was 3.3 (range 0.2–36) days. Mean weight of the babies was 3.36 (range of 2.08–4.77) kg. 30 (50%) babies had meconium aspiration syndrome, 16 (27%) had sepsis, 3 (5%) had congenital diaphragmatic hernia, and 11 (18%) had other diagnosis. The authors analysed the indications for ECMO referrals including indices of severity, ventilatory strategies, different measures taken for treating pulmonary hypertension and the complications seen during their clinical course.

The following table shows the conventional management for PPHN received by babies in referral hospitals before ECMO.

Oxygenation index (OI) at the time of referral ranged from 18 to 133. There was no documentation of OI in 18 (30%) cases. 11/18 patients had insufficient data to calculate OI. Based on the UK ECMO trail the threshold of OI for referral for ECMO is 40. 25/49 (51%) babies were referred with an OI of >40. 20/49 (40%) of babies were referred when the OI was >50. There was a wide regional variation in threshold for referral with regards to OI and also use of conventional management for PPHN in neonates in the UK. Mean duration of high pressure and FiO₂ before commencement of ECMO was 24 (2–72) h. 19/60 (32%) babies developed pneumothorax in the referral hospitals.

Conclusion The authors noted significant number of babies were referred at very high OI and after prolonged high ventilatory settings with high incidence of pneumothoraces from tertiary referral centres, resulting in increased duration of ECMO course. Our study signifies the importance of increasing the awareness in neonatologists and paediatricians about the indications for ECMO referral to avoid unnecessary delay and complications.