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High-Frequency Oscillatory Ventilation and Ventilator-Induced Lung Injury: Size Does Matter. Crit Care Med 2020; 48:e66-e73. [PMID: 31634232 DOI: 10.1097/ccm.0000000000004073] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The theoretical basis for minimizing tidal volume during high-frequency oscillatory ventilation may not be appropriate when lung tissue stretch occurs heterogeneously and/or rapidly. The objective of this study was to assess the extent to which increased ventilation heterogeneity may contribute to ventilator-induced lung injury during high-frequency oscillatory ventilation in adults compared with neonates on the basis of lung size, using a computational model of human lungs. DESIGN Computational modeling study. SETTING Research laboratory. SUBJECTS High-fidelity, 3D computational models of human lungs, scaled to various sizes representative of neonates, children, and adults, with varying injury severity. All models were generated from one thoracic CT image of a healthy adult male. INTERVENTIONS Oscillatory ventilation was simulated in each lung model at frequencies ranging from 0.2 to 40 Hz. Sinusoidal flow oscillations were delivered at the airway opening of each model and distributed through the lungs according to regional parenchymal mechanics. MEASUREMENTS AND MAIN RESULTS Acinar flow heterogeneity was assessed by the coefficient of variation in flow magnitudes across all acini in each model. High-frequency oscillatory ventilation simulations demonstrated increasing heterogeneity of regional parenchymal flow with increasing lung size, with decreasing ratio of deadspace to total acinar volume, and with increasing frequency above lung corner frequency and resonant frequency. Potential for resonant amplification was greatest in injured adult-sized lungs with higher regional quality factors indicating the presence of underdamped lung regions. CONCLUSIONS The potential for ventilator-induced lung injury during high-frequency oscillatory ventilation is enhanced at frequencies above lung corner frequency or resonant frequency despite reduced tidal volumes, especially in adults, due to regional amplification of heterogeneous flow. Measurements of corner frequency and resonant frequency should be considered during high-frequency oscillatory ventilation management.
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Wong JJM, Liu S, Dang H, Anantasit N, Phan PH, Phumeetham S, Qian S, Ong JSM, Gan CS, Chor YK, Samransamruajkit R, Loh TF, Feng M, Lee JH. The impact of high frequency oscillatory ventilation on mortality in paediatric acute respiratory distress syndrome. Crit Care 2020; 24:31. [PMID: 32005285 PMCID: PMC6995130 DOI: 10.1186/s13054-020-2741-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 01/14/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND High-frequency oscillatory ventilation (HFOV) use was associated with greater mortality in adult acute respiratory distress syndrome (ARDS). Nevertheless, HFOV is still frequently used as rescue therapy in paediatric acute respiratory distress syndrome (PARDS). In view of the limited evidence for HFOV in PARDS and evidence demonstrating harm in adult patients with ARDS, we hypothesized that HFOV use compared to other modes of mechanical ventilation is associated with increased mortality in PARDS. METHODS Patients with PARDS from 10 paediatric intensive care units across Asia from 2009 to 2015 were identified. Data on epidemiology and clinical outcomes were collected. Patients on HFOV were compared to patients on other modes of ventilation. The primary outcome was 28-day mortality and secondary outcomes were 28-day ventilator- (VFD) and intensive care unit- (IFD) free days. Genetic matching (GM) method was used to analyse the association between HFOV treatment with the primary outcome. Additionally, we performed a sensitivity analysis, including propensity score (PS) matching, inverse probability of treatment weighting (IPTW) and marginal structural modelling (MSM) to estimate the treatment effect. RESULTS A total of 328 patients were included. In the first 7 days of PARDS, 122/328 (37.2%) patients were supported with HFOV. There were significant differences in baseline oxygenation index (OI) between the HFOV and non-HFOV groups (18.8 [12.0, 30.2] vs. 7.7 [5.1, 13.1] respectively; p < 0.001). A total of 118 pairs were matched in the GM method which found a significant association between HFOV with 28-day mortality in PARDS [odds ratio 2.3, 95% confidence interval (CI) 1.3, 4.4, p value 0.01]. VFD was indifferent between the HFOV and non-HFOV group [mean difference - 1.3 (95%CI - 3.4, 0.9); p = 0.29] but IFD was significantly lower in the HFOV group [- 2.5 (95%CI - 4.9, - 0.5); p = 0.03]. From the sensitivity analysis, PS matching, IPTW and MSM all showed consistent direction of HFOV treatment effect in PARDS. CONCLUSION The use of HFOV was associated with increased 28-day mortality in PARDS. This study suggests caution but does not eliminate equivocality and a randomized controlled trial is justified to examine the true association.
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Affiliation(s)
- Judith Ju-Ming Wong
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore.
| | - Siqi Liu
- Saw Swee Hock School of Public Health, National University Health System, NUS Graduate School for Integrative Science and Engineering, National University of Singapore, 12 Science Drive 2, Singapore, 117549, Singapore
| | - Hongxing Dang
- Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, 136 Zhongshan 2nd Rd, Yuzhong district, Chongqing, 400041, China
| | - Nattachai Anantasit
- Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Phuc Huu Phan
- National Children's Hospital, 18/879 La Thành, Láng Thượng, Đống Đa, Hanoi, Vietnam
| | - Suwannee Phumeetham
- Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road Bangkoknoi, Bangkok, 10700, Thailand
| | - Suyun Qian
- Beijing Children's Hospital, Capital Medical University, 56 Nanlishi Rd, Xicheng District, Beijing, 100045, China
| | - Jacqueline Soo May Ong
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Chin Seng Gan
- Department of Pediatrics, University of Malaya. Jalan Universiti, 50603, Wilayah Persekutuan, Kuala Lumpur, Malaysia
| | - Yek Kee Chor
- Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia
| | - Rujipat Samransamruajkit
- Critical Care Excellence Center, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University Bangkok, Bangkok, 10330, Thailand
| | - Tsee Foong Loh
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Mengling Feng
- Saw Swee Hock School of Public Health, National University Health System, NUS Graduate School for Integrative Science and Engineering, National University of Singapore, 12 Science Drive 2, Singapore, 117549, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, Department of Pediatric Subspecialties, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
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Affiliation(s)
- Claudia Dos Santos
- 1 Interdepartmental Division of Critical Care Medicine and.,2 Division of Respirology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,3 Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Leo Heunks
- 4 Department of Intensive Care, VU University Medical Centre, Amsterdam, the Netherlands
| | - Hannah Wunsch
- 1 Interdepartmental Division of Critical Care Medicine and.,6 Department of Anesthesiology, University of Toronto, Toronto, Ontario, Canada.,5 Department of Critical Care Medicine, Sunnybrook Hospital, Toronto, Ontario, Canada; and.,7 Sunnybrook Research Institute, Toronto, Ontario, Canada
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