Feasibility of an alternative, physiologic, individualized open-lung approach to high-frequency oscillatory ventilation in children

Pauline de Jager; Tamara Kamp; Sandra K Dijkstra; Johannes G M Burgerhof; Dick G Markhorst; Martha A Q Curley; Ira M Cheifetz; Martin C J Kneyber

doi:10.1186/s13613-019-0492-0

Feasibility of an alternative, physiologic, individualized open-lung approach to high-frequency oscillatory ventilation in children

Ann Intensive Care. 2019 Jan 18;9(1):9. doi: 10.1186/s13613-019-0492-0.

Authors

Pauline de Jager¹, Tamara Kamp¹, Sandra K Dijkstra¹, Johannes G M Burgerhof², Dick G Markhorst³, Martha A Q Curley⁴, Ira M Cheifetz⁵, Martin C J Kneyber^{6

7}

Affiliations

¹ Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA 80, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
² Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
³ Department of Paediatrics, Division of Paediatric Critical Care Medicine, VU University Medical Center, Amsterdam, The Netherlands.
⁴ Family and Community Health, School of Nursing, Anesthesia and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
⁵ Department of Pediatrics, Division of Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA.
⁶ Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Huispost CA 80, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands. m.c.j.kneyber@umcg.nl.
⁷ Critical Care, Anaesthesiology, Perioperative and Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands. m.c.j.kneyber@umcg.nl.

Abstract

Background: High-frequency oscillatory ventilation (HFOV) is a common but unproven management strategy in paediatric critical care. Oscillator settings have been traditionally guided by patient age and/or weight rather than by lung mechanics, thereby potentially negating any beneficial effects. We have adopted an open-lung HFOV strategy based on a corner frequency approach using an initial incremental-decremental mean airway pressure titration manoeuvre, a high frequency (8-15 Hz), and high power to initially target a proximal pressure amplitude (∆P_proximal) of 70-90 cm H₂O, irrespective of age or weight.

Methods: We reviewed prospectively collected data on patients < 18 years of age who were managed with HFOV for acute respiratory failure. We measured metrics for oxygenation, ventilation, and haemodynamics as well as the use of sedative-analgesic medications and neuromuscular blocking agents.

Results: Data from 115 non-cardiac patients were analysed, of whom 53 had moderate-to-severe paediatric acute respiratory distress syndrome (PARDS). Sixteen patients (13.9%) died. Frequencies≥ 8 Hz and high ∆P_proximal were achieved in all patients irrespective of age or PARDS severity. Patients with severe PARDS showed the greatest improvement in oxygenation. pH and PaCO₂ normalized in all patients. Haemodynamic parameters, cumulative amount of fluid challenges, and daily fluid balance did not deteriorate after transitioning to HFOV in any age or PARDS severity group. We observed a transient increase neuromuscular blocking agent use after switching to HFOV, but there was no increase in the daily cumulative amount of continuous midazolam or morphine in any age or PARDS severity group. No patients experienced clinically apparent barotrauma.

Conclusions: This is the first study reporting the feasibility of an alternative, individualized, physiology-based open-lung HFOV strategy targeting high F and high ∆P_proximal. No adverse effects were observed with this strategy. Our findings warrant further systematic evaluation.

Keywords: Acute respiratory failure; Child; High-frequency oscillatory ventilation; Mechanical ventilation; Oxygenation; Paediatric acute respiratory distress syndrome; Paediatrics.