Bone Marrow Transplantation, (1998) 22 , 787–794  1998 Stockton Press All rights reserved 0268–3369/98 $12.00 http:/ / www.stockton-press.co.uk/ bmt Outcomes following mechanical ventilation in children undergoing bone marrow transplantation AB Warwick 1 , AC Mertens 2 , X Ou Shu 2 , NKC Ramsay 3 and JP Neglia 4 1 Division of Pediatric Hematology/Oncology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI; 2 Division of Pediatric Epidemiology and Clinical Research, 3 Bone Marrow Transplant Program, Department of Pediatrics, and 4 Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA Summary: Between 1976 and 1992, 869 patients 19 years of age underwent BMT at the University of Minnesota for a variety of malignant and non-malignant disorders. One hundred and ninety-six required mechanical ventilation (MV) at some time from the start of pre-BMT cyto reduction through the first year following BMT. Reasons for MV included respiratory compromise, upper airway management and non-pulmonary indi- cations for respiratory support. In multivariate models, underlying diagnosis, receipt of HLA-mismatched mar- row and the presence of acute graft-versus-host disease (aGVHD) were independent predictors of the need for MV. Indication for MV, underlying diagnosis, and pres- ence of aGVHD were independent predictors of success- ful extubation. Overall survival at 2 years was 14% among MV patients and 52% among non-MV patients. While the need for MV during BMT reduces the overall likelihood of survival, 40% of children who required MV were successfully extubated; 35% of these extub- ated patients were long-term survivors. This outcome is better than that reported for adult BMT patients requiring respiratory support, who show survival of 5% at 6 months following BMT. Our data suggest extrapolation of outcome data from adult to pediatric patients is not appropriate and aggressive care of pedi- atric patients requiring respiratory support is not futile. Keywords: mechanical ventilation; marrow transplan- tation; children; pulmonary complications Bone marrow transplantation (BMT), autologous and allo- geneic, has become part of standard therapy for patients with leukemia, solid tumors, immunologic diseases, aplas- tic anemia and metabolic disorders correctable by infusion of normal hematopoietic stem cells. 1,2 Much of the mor- bidity associated with BMT is due to complications arising from the transplant process including direct toxicities of the radiation and/or drugs used in preparative regimens, as well as infections and bleeding complications that result from Correspondence: Dr AB Warwick, Department of Pediatrics, Medical Col- lege of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA Received 9 March 1998; accepted 28 May 1998 the prolonged marrow suppression. In addition, graft- versus-host disease (GVHD) can add to morbidity and mortality in recipients of allogeneic marrow. 1 As preparative regimens for bone marrow transplantation become more aggressive, patients require more intensive support, which may include mechanical ventilation (MV). The use of MV has been associated with a poor outcome for bone marrow transplant recipients. In two retrospective studies, 5% of all patients placed on ventilators during BMT were reported to survive 6 months after extubation; 3,4 most of these patients were adults. One of the tenets of pediatric practice is that children are not small adults. Our clinical impression prior to this study suggested that chil- dren requiring MV during BMT had a better prognosis than that reported in the literature. An understanding of the risks and benefits associated with MV for respiratory failure or other indications is important for both pre-transplant coun- seling and informed choices during and after transplant by physicians, patients, and their families. We examined a 16- year cohort of pediatric BMT patients to identify the characteristics of patients who required MV support and the factors associated with patient outcome after MV. Materials and methods Subjects All patients less than 19 years of age at time of BMT at the University of Minnesota between January 1976 and December 1992 were included in the study (n = 896). Of these, 196 required MV at some time from the start of pre- BMT cytoreduction through the first year following BMT. As of July 1993, the minimum follow-up period from time of transplant was 6 months. Methods The University of Minnesota BMT database contains demo- graphic information of each patient transplanted at the Uni- versity Hospital as well as clinical data collected prospec- tively during and after transplant. This database was used to extract a complete dataset of eligible patients along with information about their conditioning regimen, date and type of BMT, status of HLA match, GVHD prophylaxis, original disease and remission status, current status and status date, and details of pulmonary problems during or after the trans-