High-frequency oscillatory ventilation for acute respiratory distress syndrome in adult patients

Introduction: High-frequency oscillatory ventilation (HFOV) using an open-lung strategy has been demonstrated to improve oxygenation in neonatal and pediatric respiratory failure, without increasing barotrauma. Animal studies using small (<4 mm) endotracheal tubes have shown reduced histopathologic evidence of lung injury and inflammatory mediator release, suggesting reduced ventilator-induced lung injury. Clinical Studies: During the last decade, case reports and observational studies of HFOV in patients failing conventional ventilation strategies have suggested improved oxygenation in adult patients with severe acute respiratory distress syndrome. These reports have also suggested that early (2 days) initiation of HFOV is more likely to result in survival than delayed initiation (>7 days). A recently published randomized, controlled trial in acute respiratory distress syndrome patients (n = 148) comparing HFOV with a pressure-control ventilation strategy (PaO2/FIO2 ratio of less than or equal to200 mm Hg on positive end-expiratory pressure of >10 cm H2O) demonstrated early (<16 hrs) improvement in PaO2/FiO(2) (p =.008) in the HFOV group but no significant difference in oxygenation index between the two groups during the initial 72 hrs of treatment. Thirty-day mortality was 37% in the HFOV group 52% in the conventional ventilation group (p=.102). There was no significant difference between treatment groups in the prevalence of barotrauma, hemodynamic instability, or mucus plugging. This study suggests that HFOV is as effective and safe as the conventional strategy to which it was compared. Clinical Application: For clinical use in adults, a trial of HFOV may be considered when FIO2 requirements exceed 60% and mean airway pressure is approaching 20 cm H2O or higher (or, alternatively, positive end-expiratory pressure of >15 cm H2O). It is currently unknown whether initiating HFOV at a lower severity threshold would result in reduced ventilator-associated lung injury or mortality. Future Directions: Future studies should compare different algorithms of applying HFOV to determine the optimal techniques for achieving oxygenation and ventilation, while minimizing ventilator-associated lung injury. The potential role of adjunctive therapies used with HFOV (e.g., prone ventilation, inhaled nitric oxide, aerosolized vasodilators, liquid ventilation) will require further research.