TY - JOUR
T1 - High-frequency oscillation for adult patients with acute respiratory distress syndrome
T2 - A systematic review and meta-analysis
AU - Goligher, Ewan C.
AU - Munshi, Laveena
AU - Adhikari, Neill K.J.
AU - Meade, Maureen O.
AU - Hodgson, Carol L.
AU - Wunsch, Hannah
AU - Uleryk, Elizabeth
AU - Gajic, Ognjen
AU - Amato, Marcelo P.B.
AU - Ferguson, Niall D.
AU - Rubenfeld, Gordon D.
AU - Fan, Eddy
N1 - Funding Information:
Supported by a postdoctoral fellowship from the Canadian Institutes of Health Research (E.C.G.). The funding agency had no role in the conduct of the study or the publication of the results.
Funding Information:
A range of strategies has been proposed to reduce mechanical stress and strain during mechanical ventilation, such as lower tidal volumes, higher positive end-expiratory pressure (PEEP), lung recruitment maneuvers, prone ventilation, and neuromuscular blockade (9). High-frequency oscillatory ventilation (HFOV) employs novel mechanisms of alveolar ventilation aside from bulk gas flow, permitting the delivery of very small tidal volumes at higher mean airway pressures (10, 11). By simultaneously recruiting collapsed lung units and minimizing tidal stress and strain, HFOV offers a theoretically ideal mode of lung protection (10, 12, 13). HFOV requires specialized expertise, and patients must be heavily sedated to prevent tidal inspiratory efforts; consequently, the overall impact of HFOV on patient outcomes in ARDS is controversial (14). We undertook a systematic review of randomized trials of HFOV to inform a Clinical Practice Guideline sponsored by the American Thoracic Society and the Society of Critical Care Medicine. Specifically, we aimed to determine whether HFOV improves survival in adult patients with ARDS compared with conventional mechanical ventilation in randomized controlled trials.
Publisher Copyright:
Copyright © 2017 by the American Thoracic Society.
PY - 2017/10
Y1 - 2017/10
N2 - Rationale: By minimizing tidal lung strain and maintaining alveolar recruitment, high-frequency oscillatory ventilation (HFOV) may protect against ventilator-induced lung injury. Objectives: To summarize the current evidence in support of the use of HFOV in adult patients with acute respiratory distress syndrome. Methods: We conducted a systematic review and meta-analysis of randomized trials comparing mortality rates with the use of HFOV versus conventional mechanical ventilation for adult patients with acute respiratory distress syndrome. Eligible trials were identified from previously published systematic reviews and an updated literature search. Data on 28-day mortality, oxygenation, adverse events, and use of rescue therapies were collected; effects were pooled using random effects models weighted by inverse variance. Strength of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation methodology. Results: Six trials were eligible for inclusion (total n = 1,715 patients). Four trials mandated lung-protective ventilation in the control group and one trial applied a higher positive end-expiratory pressure (PEEP) ventilation strategy in the control group. None of the trials were judged to be at high risk of bias, though all were unblinded. In trials that did not systematically employ any cointerventions with HFOV and that targeted low tidal volumes in the patients randomized to conventional ventilation (primary analysis), HFOV had no significant effect on mortality (three trials; risk ratio [RR], 1.14; 95% confidence interval [CI], 0.88 to 1.48; evidence grade = high). Pooled analysis of all six trials also did not suggest a significant mortality reduction (RR, 0.94; 95% CI, 0.71 to 1.24; evidence grade = low). The single trial that employed a conventional ventilation strategy with both lower tidal volumes and higher PEEP as control reported higher mortality in patients receiving HFOV (RR, 1.41; 95% CI, 1.12 to 1.79). HFOV was not associated with improved oxygenation after 24 hours (five trials; mean increase of 10 mm Hg; 95% CI, - 16 to 37 mm Hg). Rates of barotrauma were not different between HFOV and conventional ventilation, although significant benefit or harm could not be excluded (RR, 1.15; 95% CI, 0.61 to 2.17). Conclusions: Published randomized trials suggest that HFOV is not associated with a mortality benefit, and may even be harmful in comparison to ventilation with low tidal volumes and higher levels of PEEP.
AB - Rationale: By minimizing tidal lung strain and maintaining alveolar recruitment, high-frequency oscillatory ventilation (HFOV) may protect against ventilator-induced lung injury. Objectives: To summarize the current evidence in support of the use of HFOV in adult patients with acute respiratory distress syndrome. Methods: We conducted a systematic review and meta-analysis of randomized trials comparing mortality rates with the use of HFOV versus conventional mechanical ventilation for adult patients with acute respiratory distress syndrome. Eligible trials were identified from previously published systematic reviews and an updated literature search. Data on 28-day mortality, oxygenation, adverse events, and use of rescue therapies were collected; effects were pooled using random effects models weighted by inverse variance. Strength of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation methodology. Results: Six trials were eligible for inclusion (total n = 1,715 patients). Four trials mandated lung-protective ventilation in the control group and one trial applied a higher positive end-expiratory pressure (PEEP) ventilation strategy in the control group. None of the trials were judged to be at high risk of bias, though all were unblinded. In trials that did not systematically employ any cointerventions with HFOV and that targeted low tidal volumes in the patients randomized to conventional ventilation (primary analysis), HFOV had no significant effect on mortality (three trials; risk ratio [RR], 1.14; 95% confidence interval [CI], 0.88 to 1.48; evidence grade = high). Pooled analysis of all six trials also did not suggest a significant mortality reduction (RR, 0.94; 95% CI, 0.71 to 1.24; evidence grade = low). The single trial that employed a conventional ventilation strategy with both lower tidal volumes and higher PEEP as control reported higher mortality in patients receiving HFOV (RR, 1.41; 95% CI, 1.12 to 1.79). HFOV was not associated with improved oxygenation after 24 hours (five trials; mean increase of 10 mm Hg; 95% CI, - 16 to 37 mm Hg). Rates of barotrauma were not different between HFOV and conventional ventilation, although significant benefit or harm could not be excluded (RR, 1.15; 95% CI, 0.61 to 2.17). Conclusions: Published randomized trials suggest that HFOV is not associated with a mortality benefit, and may even be harmful in comparison to ventilation with low tidal volumes and higher levels of PEEP.
KW - Acute respiratory distress syndrome
KW - Artificial
KW - Lung recruitment
KW - Positive end-expiratory pressure
KW - Respiration
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U2 - 10.1513/AnnalsATS.201704-341OT
DO - 10.1513/AnnalsATS.201704-341OT
M3 - Review article
C2 - 29043832
AN - SCOPUS:85032462616
VL - 14
SP - S289-S296
JO - Annals of the American Thoracic Society
JF - Annals of the American Thoracic Society
SN - 2325-6621
ER -