High-Frequency Oscillation for ARDS

McDermid, Robert C.; Csanyi-Fritz, Yvonne

doi:10.1056/nejmc1304344

Cited by 7 publications

(1 citation statement)

References 15 publications

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“…The tested 7-Hz HFO strategy was aimed at approximating the HFO ventilatory conditions of the recent, large, and neutral/negative HFO trials [7, 8]. These trials actually assessed the effect of HFO on lung protection without concurrently focusing on RV protection [9, 10]; according to our results, simultaneous RV exposure to high intrathoracic pressures and hypercapnia can promptly cause new RV dysfunction or failure.…”

Section: Discussionmentioning

confidence: 99%

“Low-” versus “high”-frequency oscillation and right ventricular function in ARDS. A randomized crossover study

Mentzelopoulos¹,

Anninos²,

Malachias³

et al. 2018

j intensive care

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BackgroundRecent, large trials of high-frequency oscillation (HFO) versus conventional ventilation (CV) in acute respiratory distress syndrome (ARDS) reported negative results. This could be explained by an HFO-induced right ventricular (RV) dysfunction/failure due to high intrathoracic pressures and hypercapnia. We hypothesized that HFO strategies aimed at averting/attenuating hypercapnia, such as “low-frequency” (i.e., 4 Hz) HFO and 4-Hz HFO with tracheal-gas insufflation (HFO-TGI), may result in an improved RV function relative to “high-frequency” (i.e., 7 Hz) HFO (which may promote hypercapnia) and similar RV function relative to lung protective CV.MethodsWe studied 17 patients with moderate-to-severe ARDS [PaO2-to-inspiratory O2 fraction ratio (PaO2/FiO2) < 150]. RV function was assessed by transesophageal echocardiography (TEE). Patients received 60 min of CV for TEE-guided, positive end-expiratory pressure (PEEP) “optimization” and subsequent stabilization; 60 min of 4-Hz HFO for “study mean airway pressure (mPaw)” titration to peripheral oxygen saturation ≥ 95%, without worsening RV function as assessed by TEE; 60 min of each tested HFO strategy in random order; and another 60 min of CV using the pre-HFO, TEE-guided PEEP setting. Study measurements (i.e., gas exchange, hemodynamics, and TEE data) were obtained over the last 10 min of pre-HFO CV, of each one of the three tested HFO strategies, and of post-HFO CV.ResultsThe mean “study HFO mPaw” was 8–10 cmH2O higher relative to pre-HFO CV. Seven-Hz HFO versus 4-Hz HFO and 4-Hz HFO-TGI resulted in higher mean ± SD right-to-left ventricular end-diastolic area ratio (RVEDA/LVEDA) (0.64 ± 0.15 versus 0.56 ± 0.14 and 0.52 ± 0.10, respectively, both p < 0.05). Higher diastolic/systolic eccentricity indexes (1.33 ± 0.19/1.42 ± 0.17 versus 1.21 ± 0.10/1.26 ± 0.10 and 1.17 ± 0.11/1.17 ± 0.13, respectively, all p < 0.05). Seven-Hz HFO resulted in 18–28% higher PaCO2 relative to all other ventilatory strategies (all p < 0.05). Four-Hz HFO-TGI versus pre-HFO CV resulted in 15% lower RVEDA/LVEDA, and 7%/10% lower diastolic/systolic eccentricity indexes (all p < 0.05). Mean PaO2/FiO2 improved by 77–80% during HFO strategies versus CV (all p < 0.05). Mean cardiac index varied by ≤ 10% among strategies. Percent changes in PaCO2 among strategies were predictive of concurrent percent changes in measures of RV function (R2 = 0.21–0.43).ConclusionsIn moderate-to-severe ARDS, “short-term” 4-Hz HFO strategies resulted in better RV function versus 7-Hz HFO, partly attributable to improved PaCO2 control, and similar or improved RV function versus CV.Trial registrationThis study was registered 40 days prior to the enrollment of the first patient at ClinicalTrials.gov, ID no. NCT02027129, Principal Investigator Spyros D. Mentzelopoulos, date of registration January 3, 2014.Electronic supplementary materialThe online version of this article (10.1186/s40560-018-0327-3) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

“Low-” versus “high”-frequency oscillation and right ventricular function in ARDS. A randomized crossover study

Mentzelopoulos¹,

Anninos²,

Malachias³

et al. 2018

j intensive care

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Indications for Nonconventional Ventilation Modes

Bollen

Danan²,

Durrmeyer³

et al. 2014

Pediatric and Neonatal Mechanical Ventilation

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Physiology in Medicine: Understanding dynamic alveolar physiology to minimize ventilator-induced lung injury

Nieman

Satalin

Kollisch-Singule

et al. 2017

Journal of Applied Physiology

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Acute respiratory distress syndrome (ARDS) remains a serious clinical problem with the main treatment being supportive in the form of mechanical ventilation. However, mechanical ventilation can be a double-edged sword: if set improperly, it can exacerbate the tissue damage caused by ARDS; this is known as ventilator-induced lung injury (VILI). To minimize VILI, we must understand the pathophysiologic mechanisms of tissue damage at the alveolar level. In this Physiology in Medicine paper, the dynamic physiology of alveolar inflation and deflation during mechanical ventilation will be reviewed. In addition, the pathophysiologic mechanisms of VILI will be reviewed, and this knowledge will be used to suggest an optimal mechanical breath profile (MB: all airway pressures, volumes, flows, rates, and the duration that they are applied at both inspiration and expiration) necessary to minimize VILI. Our review suggests that the current protective ventilation strategy, known as the "open lung strategy," would be the optimal lung-protective approach. However, the viscoelastic behavior of dynamic alveolar inflation and deflation has not yet been incorporated into protective mechanical ventilation strategies. Using our knowledge of dynamic alveolar mechanics (i.e., the dynamic change in alveolar and alveolar duct size and shape during tidal ventilation) to modify the MB so as to minimize VILI will reduce the morbidity and mortality associated with ARDS.

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High-Frequency Oscillation for ARDS

Cited by 7 publications

References 15 publications

“Low-” versus “high”-frequency oscillation and right ventricular function in ARDS. A randomized crossover study

“Low-” versus “high”-frequency oscillation and right ventricular function in ARDS. A randomized crossover study

Indications for Nonconventional Ventilation Modes

Physiology in Medicine: Understanding dynamic alveolar physiology to minimize ventilator-induced lung injury

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