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Communications to the Editor |

High-Frequency Ventilation and the Prevention of Ventilator-Associated Lung Injury High-Frequency Ventilation and the Prevention of Ventilator-Associated Lung Injury FREE TO VIEW

Thomas Hoehn, MD; Christoph Bührer, MD, PhD
Author and Funding Information

Affiliations: Humboldt University, Charité Virchow Hospital Berlin, Germany,  Johns Hopkins University Baltimore, MD

Correspondence to: Thomas Hoehn, MD, Department of Neonatology, Charité, Campus Virchow-Klinikum, Humboldt University, Augustenburger Platz 1, D-13353 Berlin, Germany; e-mail: thomas.hoehn@charite.de



Chest. 2001;119(6):1978-1979. doi:10.1378/chest.119.6.1978
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With great interest, we read the article by Jerry A. Krishnan and Roy G. Brower that appeared in a recent issue of CHEST (September 2000).1We fully agree that every effort should be undertaken to minimize the occurrence of ventilator-associated lung injury. By avoiding stretch-induced injury, which is caused by high end-inspiratory and low end-expiratory lung volumes, high-frequency ventilation (HFV) potentially offers a gentler mode of ventilation. The majority of randomized controlled trials of HFV have been conducted in preterm neonates, although three Cochrane Reviews24 have been published. Although the predominant underlying disease in these reviews was a homogeneous parenchymal lung disease (respiratory distress syndrome), therapeutic options were so heterogeneously modified as to render the reviewer’s statements inconclusive. However, with respect to the specific techniques of HFV (high-frequency oscillatory ventilation vs high-frequency jet ventilation [HFJV]), a few comments are appropriate. First, HFJV in the treatment of respiratory distress syndrome in preterm infants has been associated with a greater risk for adverse outcome (ie, severe intracranial hemorrhage, cystic periventricular leukomalacia, or death).5 Second, the only study that demonstrated a reduced incidence of chronic lung disease in preterm infants was the Provo trial.6 This trial was performed with the use of an oscillatory device of the diaphragm type, and a high-volume strategy was applied. The term “high-volume strategy” refers to the degree of lung expansion achieved during HFV and corresponds to the lung protective concept of reduced end-inspiratory and increased end-expiratory lung volumes. Taken together, the neonatal data published so far have shown efficacy as well as safety exclusively for the oscillator type of HFV.

A more uniform lung expansion during HFV has additional advantages, which were not discussed by Krishnan and Brower. The distribution of inhaled nitric oxide (iNO), which is frequently used in ARDS treatment regimens, happens in a more homogenous manner and therefore can be enhanced by HFV. The coadministration of HFV and iNO leads to an improved oxygenation compared to either HFV or iNO alone, which has been shown in preterm as well as in term newborns with acute lung injury (ALI) and pulmonary hypertension.78 In addition, a more uniform lung expansion prevents alveolar collapse and secondary surfactant inactivation in nonventilated lung areas. High-frequency oscillatory ventilation turned out to significantly reduce the number of redosing surfactant in the treatment of neonatal respiratory distress syndrome.6

Clearly, randomized controlled trials establishing the potential role of HFV in adult patients with ALI/ARDS are highly desirable. Data from animal models readily document a superiority of HFV over conventional ventilation once traditional ventilation strategies are employed (ie, tidal volumes of 8 to 10 mL/kg).9 Applying lung protective strategies during conventional ventilation may ultimately complicate the proof of HFV superiority but will certainly be beneficial for patients with ALI/ARDS.

Krishnan, JA, Brower, RG (2000) High-frequency ventilation for acute lung injury and ARDS.Chest118,795-807. [CrossRef] [PubMed]
 
Bhuta, T, Henderson-Smart, DJ Rescue high frequency oscillatory ventilation versus conventional ventilation for pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev. 2000;;2 ,.:CD000438. [PubMed]
 
Bhuta, T, Henderson-Smart, DJ Elective high frequency jet ventilation versus conventional ventilation for respiratory distress syndrome in preterm infants. Cochrane Database Syst Rev. 2000;;2 ,.:CD000328. [PubMed]
 
Henderson-Smart, DJ, Bhuta, T, Cools, F, et al Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev. 2000;;2 ,.:CD000104. [PubMed]
 
Wiswell, TE, Graziani, LJ, Kornhauser, MS, et al High-frequency jet ventilation in the early management of respiratory distress syndrome is associated with a greater risk for adverse outcomes.Pediatrics1996;98,1035-1043. [PubMed]
 
Gerstmann, DR, Minton, SD, Stoddard, RA, et al The Provo multicenter early high-frequency oscillatory ventilation trial: improved pulmonary and clinical outcome in respiratory distress syndromePediatrics1996;98,1044-1057. [PubMed]
 
Kinsella, JP, Truog, WE, Walsh, WF, et al Randomized, multicenter trial of inhaled nitric oxide and high-frequency oscillatory ventilation in severe, persistent pulmonary hypertension of the newborn.J Pediatr1997;131,55-62. [CrossRef] [PubMed]
 
Kinsella, JP, Abman, SH High-frequency oscillatory ventilation augments the response to inhaled nitric oxide in persistent pulmonary hypertension of the newborn: Nitric Oxide Study Group [abstract]. Chest. 1998;;114(suppl) ,.:100S
 
Huang, QW, Sun, B, Gao, F, et al Effects of inhaled nitric oxide and high-frequency ventilation in rabbits with meconium aspiration.Biol Neonate1999;76,374-382. [CrossRef] [PubMed]
 

High-Frequency Ventilation and the Prevention of Ventilator-Associated Lung Injury

To the Editor:

We agree that additional studies are necessary to evaluate the clinical benefit of high-frequency ventilation (HFV) as a lung protective strategy in adults with acute lung injury and ARDS (ALI/ARDS). Studies in animals and neonates are particularly promising for the use of high-frequency oscillation (HFO), a form of HFV. Two studies12 in premature neonates with respiratory distress syndrome discussed in our review (one cited by Drs. Hoehn and Bührer1) suggested that HFO reduces the incidence of chronic lung disease compared to conventional ventilation.

The study by Kinsella et al3 found that oxygenation was similar in neonates with persistent pulmonary hypertension randomized to conventional ventilation with inhaled nitric oxide (iNO) compared to HFO alone. Neonates without improved oxygenation (Pao2 < 60 mm Hg with fraction of inspired oxygen = 1.0 at 2 h) following the initial treatment assignment were crossed over to the alternate strategy. Lack of improvement in oxygenation following crossover led to treatment with HFO and iNO. HFO combined with iNO improved oxygenation in 32% of neonates whose oxygenation did not improve with conventional ventilation and iNO or HFO alone following crossover. While the response to HFO with iNO is encouraging, the lack of prospectively identified control group for this combined strategy limits the interpretation of the results. We look forward to studies in adults with ALI/ARDS.

References
Gerstmann, DR, Minton, SD, Stodard, RA, et al The Provo multicenter early high-frequency oscillatory ventilation trial: improved pulmonary and clinical outcomes in respiratory distress syndrome.Pediatrics1996;98,1044-1057. [PubMed]
 
Clark, RH, Gerstmann, DR, Null, DM, Jr, et al Prospective randomized comparison of high-frequency oscillatory and conventional ventilation in respiratory distress syndrome.Pediatrics1992;89,5-12. [PubMed]
 
Kinsella, JP, Truog, WE, Walsh, WF, et al Randomized, multicenter trial of inhaled nitric oxide and high-frequency oscillatory ventilation in severe, persistent pulmonary hypertension of the newborn.J Pediatr1997;131,55-62. [CrossRef] [PubMed]
 

Figures

Tables

References

Krishnan, JA, Brower, RG (2000) High-frequency ventilation for acute lung injury and ARDS.Chest118,795-807. [CrossRef] [PubMed]
 
Bhuta, T, Henderson-Smart, DJ Rescue high frequency oscillatory ventilation versus conventional ventilation for pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev. 2000;;2 ,.:CD000438. [PubMed]
 
Bhuta, T, Henderson-Smart, DJ Elective high frequency jet ventilation versus conventional ventilation for respiratory distress syndrome in preterm infants. Cochrane Database Syst Rev. 2000;;2 ,.:CD000328. [PubMed]
 
Henderson-Smart, DJ, Bhuta, T, Cools, F, et al Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev. 2000;;2 ,.:CD000104. [PubMed]
 
Wiswell, TE, Graziani, LJ, Kornhauser, MS, et al High-frequency jet ventilation in the early management of respiratory distress syndrome is associated with a greater risk for adverse outcomes.Pediatrics1996;98,1035-1043. [PubMed]
 
Gerstmann, DR, Minton, SD, Stoddard, RA, et al The Provo multicenter early high-frequency oscillatory ventilation trial: improved pulmonary and clinical outcome in respiratory distress syndromePediatrics1996;98,1044-1057. [PubMed]
 
Kinsella, JP, Truog, WE, Walsh, WF, et al Randomized, multicenter trial of inhaled nitric oxide and high-frequency oscillatory ventilation in severe, persistent pulmonary hypertension of the newborn.J Pediatr1997;131,55-62. [CrossRef] [PubMed]
 
Kinsella, JP, Abman, SH High-frequency oscillatory ventilation augments the response to inhaled nitric oxide in persistent pulmonary hypertension of the newborn: Nitric Oxide Study Group [abstract]. Chest. 1998;;114(suppl) ,.:100S
 
Huang, QW, Sun, B, Gao, F, et al Effects of inhaled nitric oxide and high-frequency ventilation in rabbits with meconium aspiration.Biol Neonate1999;76,374-382. [CrossRef] [PubMed]
 
Gerstmann, DR, Minton, SD, Stodard, RA, et al The Provo multicenter early high-frequency oscillatory ventilation trial: improved pulmonary and clinical outcomes in respiratory distress syndrome.Pediatrics1996;98,1044-1057. [PubMed]
 
Clark, RH, Gerstmann, DR, Null, DM, Jr, et al Prospective randomized comparison of high-frequency oscillatory and conventional ventilation in respiratory distress syndrome.Pediatrics1992;89,5-12. [PubMed]
 
Kinsella, JP, Truog, WE, Walsh, WF, et al Randomized, multicenter trial of inhaled nitric oxide and high-frequency oscillatory ventilation in severe, persistent pulmonary hypertension of the newborn.J Pediatr1997;131,55-62. [CrossRef] [PubMed]
 
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