Is there still a role for high-frequency oscillatory ventilation in neonates, children and adults?

Abstract

Critically ill patients with respiratory pathology often require mechanical ventilation and while low tidal volume ventilation has become the mainstay of treatment, achieving adequate gas exchange may not be attainable with conventional ventilator modalities. In attempt to achieve gas exchange goals and also mitigate lung injury, high frequency ventilation is often implemented which couples low tidal volumes with sustained mean airway pressure. This manuscript presents the physiology of high-frequency oscillatory ventilation, reviews the currently available data on its use and provides strategies and approaches for this mode of ventilation.

Keywords:

• acute respiratory distress syndrome
• high frequency
• high-frequency oscillatory ventilation
• mechanical ventilation
• pediatric
• ventilator-induced lung injury

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Mechanical ventilation is used for patients of all ages with respiratory failure but has been shown to cause ventilator-induced lung injury. Ventilator-induced lung injury can be mitigated by the use of low tidal volume ventilation.

• High-frequency oscillatory ventilation (HFOV) couples small tidal volumes with continuous mean airway pressure to maintain an open lung strategy and avoid repeated opening and collapse of the alveoli. HFOV targets the safe zone of the pulmonary pressure–volume curve between a zone of hyperinflation and a zone of atelectasis.

• Neonatal data suggest HFOV improves short-term oxygenation, and select long-term outcomes, including less need for chronic oxygen therapy and lower rates of retinopathy of prematurity.

• Older investigations in children appear to demonstrate a benefit to early initiation of HFOV. More recently, there appears to be an increased mortality signal with the implementation of HFOV, but these outcomes likely reflect continued improvement in CMV and utilization of HFOV primarily as a rescue therapy.

• The cumulative data regarding HFOV in adults continues to remain unclear as numerous studies demonstrate equivalence or benefit while the recent OSCILLATE trial demonstrated increased mortality for patients treated with HFOV.

• HFOV works via a relative uncoupling of oxygenation and ventilation with mean airway pressure and FiO₂ controlling oxygenation and amplitude and frequency controlling ventilation.

• Cardiopulmonary interactions are very important in a patient supported by HFOV and care needs to be taken to support preload and cardiac output. A small fluid bolus at the time of initiation of HFOV may be necessary.

• HFOV is likely best reserved as rescue therapy for patients failing lung protective conventional ventilation. More studies are needed to better delineate the population of patients who could most benefit from HFOV.

• As the utilization of extracorporeal membrane oxygenation increases and the technology surrounding it improves, studies evaluating extracorporeal membrane oxygenation versus HFOV for respiratory failure are warranted.

Notes