Early High-Frequency Oscillatory Ventilation in Pediatric Acute Respiratory Failure. A Propensity Score Analysis

Abstract

Rationale: The use of high-frequency oscillatory ventilation (HFOV) for acute respiratory failure in children is prevalent despite the lack of efficacy data.Objectives: To compare the outcomes of patients with acute respiratory failure managed with HFOV within 24-48 hours of endotracheal intubation with those receiving conventional mechanical ventilation (CMV) and/or late HFOV.Methods: This is a secondary analysis of data from the RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) study, a prospective cluster randomized clinical trial conducted between 2009 and 2013 in 31 U.S. pediatric intensive care units. Propensity score analysis, including degree of hypoxia in the model, compared the duration of mechanical ventilation and mortality of patients treated with early HFOV matched with those treated with CMV/late HFOV.Measurements and Main Results: Among 2,449 subjects enrolled in RESTORE, 353 patients (14%) were ever supported on HFOV, of which 210 (59%) had HFOV initiated within 24-48 hours of intubation. The propensity score model predicting the probability of receiving early HFOV included 1,064 patients (181 early HFOV vs. 883 CMV/late HFOV) with significant hypoxia (oxygenation index >8). The degree of hypoxia was the most significant contributor to the propensity score model. After adjusting for risk category, early HFOV use was associated with a longer duration of mechanical ventilation (hazard ratio, 0.75; 95% confidence interval, 0.64-0.89; P = 0.001) but not with mortality (odds ratio, 1.28; 95% confidence interval, 0.92-1.79; P = 0.15) compared with CMV/late HFOV. Conclusions:In adjusted models including important oxygenation variables, early HFOV was associated with a longer duration of mechanical ventilation. These analyses make supporting the current approach to HFOV less convincing.

Variability in Usual Care Mechanical Ventilation for Pediatric Acute Respiratory Distress Syndrome: Time for a Decision Support Protocol?*

“…This is consistent with earlier observations(1;27–29) that HFOV is used only in about 10% of children with ARDS and reinforces the view that pediatric HFOV is reserved as a “rescue” modality for patients failing conventional ventilation. In our study, it appeared that once a patient stabilized, little change was made to any HFOV parameter save for inspired oxygen.…”

Association of Response to Inhaled Nitric Oxide and Duration of Mechanical Ventilation in Pediatric Acute Respiratory Distress Syndrome*

“…These results are in keeping with those of some previous studies, such as a publication by Kinsella et al[32] demonstrating decreased need for ECMO in these patients and the previously mentioned trial by Bronicki et al[30], which found decreased ECMO usage, as well as increased ventilator free days for the iNO arm. Lower usage of HFOV may be an additional mechanism for the observed decrease in duration of mechanical ventilation, as HFOV is associated with increased ventilator days[33]. The impact of decreasing ventilator and ECMO exposures may extend past hospital discharge.…”

Recent Advances in Pediatric Ventilatory Assistance

“…However, the clinical use of HFOV in this population has decreased. Recent studies demonstrated an association between early use of HFOV and worse outcome in terms of mortality in adult 62 and pediatric populations 63, 64 . However, several biases have been highlighted in the two pediatric studies regarding the methodology 65– 67 .…”