Prospective trial of high-frequency oscillation in adults with acute respiratory distress syndrome

Objective: To evaluate the safety and efficacy of high-frequency oscillatory ventilation (HFOV) in adult patients with the acute respiratory distress syndrome (ARDS) and oxygenation failure. Design: Prospective, clinical study. Setting: Intensive care and burn units of two university teaching hospitals. Patients: Twenty-four adults (10 females, 14 males, aged 48.5 +/- 15.2 yrs, Acute Physiology and Chronic Health Evaluation II score 21.5 +/- 6.9) with ARDS (lung injury score 3.4 +/- 0.6, Pa-02/Fio(2) 98.8 +/- 39.0 mm Hg, and oxygenation index 32.5 +/- 19.6) who met one of the following criteria: Pao(2) less than or equal to 65 mm Hg with Fio(2) greater than or equal to 0.6, or plateau pressure greater than or equal to 35 cm H2O. Interventions: HFOV was initiated in patients with ARDS after varying periods of conventional ventilation (CV). Mean airway pressure (Pa-w) was initially set 5 cm H2O greater than P-aw during CV, and was subsequently titrated to maintain oxygen saturation between 88% and 93% and F-io less than or equal to 0.60. Measurements and Main Results: Fio(2), P-aw, pressure amplitude of oscillation, frequency, blood pressure, heart rate, and arterial blood gases were monitored during the transition from CV to HFOV, and every 8 hrs thereafter for 72 hrs. In 16 patients who had pulmonary artery catheters in place, cardiac hemodynamics were recorded at the same time intervals. Throughout the HFOV trial, P-aw was significantly higher than that applied during CV. Within 8 hrs of HFOV application, and for the duration of the trial, Ro, and Pace, were lower, and Pao(2)/Fio(2) was higher than baseline values during CV. Significant changes in hemodynamic variables following HFOV initiation included an increase in pulmonary artery occlusion pressure (at 8 and 40 hrs) and central venous pressure (at 16 and 40 hrs), and a reduction in cardiac output throughout the course of the study. There were no significant changes in systemic or pulmonary pressure associated with initiation and maintenance of HFOV. Complications occurring during HFOV included pneumothorax in two patients and desiccation of secretions in one patient. Survival at 30 days was 33%, with survivors having been mechanically ventilated for fewer days before institution of HFOV compared with nonsurvivors (1.6 +/- 1.2 vs. 7.8 +/- 5.8 days; p = .001). Conclusions: These findings suggest that HFOV has beneficial effects on oxygenation and ventilation, and may be a safe and effective rescue therapy for patients with severe oxygenation failure. In addition, early institution of HFOV may be advantageous.