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Miller AG, Tan HL, Smith BJ, Rotta AT, Lee JH. The Physiological Basis of High-Frequency Oscillatory Ventilation and Current Evidence in Adults and Children: A Narrative Review. Front Physiol 2022; 13:813478. [PMID: 35557962 PMCID: PMC9087180 DOI: 10.3389/fphys.2022.813478] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/08/2022] [Indexed: 12/12/2022] Open
Abstract
High-frequency oscillatory ventilation (HFOV) is a type of invasive mechanical ventilation that employs supra-physiologic respiratory rates and low tidal volumes (VT) that approximate the anatomic deadspace. During HFOV, mean airway pressure is set and gas is then displaced towards and away from the patient through a piston. Carbon dioxide (CO2) is cleared based on the power (amplitude) setting and frequency, with lower frequencies resulting in higher VT and CO2 clearance. Airway pressure amplitude is significantly attenuated throughout the respiratory system and mechanical strain and stress on the alveoli are theoretically minimized. HFOV has been purported as a form of lung protective ventilation that minimizes volutrauma, atelectrauma, and biotrauma. Following two large randomized controlled trials showing no benefit and harm, respectively, HFOV has largely been abandoned in adults with ARDS. A multi-center clinical trial in children is ongoing. This article aims to review the physiologic rationale for the use of HFOV in patients with acute respiratory failure, summarize relevant bench and animal models, and discuss the potential use of HFOV as a primary and rescue mode in adults and children with severe respiratory failure.
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Affiliation(s)
- Andrew G Miller
- Duke University Medical Center, Respiratory Care Services, Durham, NC, United States
| | - Herng Lee Tan
- KK Women's and Children's Hospital, Children's Intensive Care Unit, Singapore, Singapore
| | - Brian J Smith
- University of California, Davis, Respiratory Care Services, Sacramento, CA, United States
| | - Alexandre T Rotta
- Duke University Medical Center, Division of Pediatric Critical Care Medicine, Durham, NC, United States
| | - Jan Hau Lee
- KK Women's and Children's Hospital, Children's Intensive Care Unit, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
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Rézaiguia-Delclaux S, Haddad F, Pilorge C, Amsallem M, Fadel E, Stéphan F. Limitations of right ventricular annular parameters in the early postoperative period following pulmonary endarterectomy: an observational study. Interact Cardiovasc Thorac Surg 2020; 31:191-198. [PMID: 32577738 DOI: 10.1093/icvts/ivaa088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/11/2020] [Accepted: 04/19/2020] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVES Echocardiographic right ventricular (RV) annular parameters are probably not as reliable to evaluate the surgical success in the postoperative period after pulmonary endarterectomy (PEA), whereas RV end-diastolic/left ventricular end-diastolic area ratio (RVEDA/LVEDA ratio) could be more useful. This study examined the relationship between RV annular parameters or RVEDA/LVEDA ratio and ideal cardiac index (ICI), before and after PEA. METHODS Among 80 patients who underwent PEA, the relationships between RVEDA/LVEDA ratio (21 patients), or tricuspid annular plane systolic excursion (32 patients), or systolic tricuspid annular velocity (55 patients) and ICI were modelled. RESULTS Forty-eight hours following PEA, mean pulmonary artery pressure decreased (26 ± 6 vs 46 ± 12 mmHg, P < 0.0001) and ICI improved (2.8 ± 0.8 vs 3.0 ± 0.9 l/min/m2, P = 0.02). In contrast to the moderate association between RV annular indices and ICI in the preoperative period, no significant relationship was found in the postoperative period (r = 0.54 and 0.17 for tricuspid annular plane systolic excursion and r = 0.46 and 0.16 for systolic tricuspid annular velocity, respectively). The RVEDA/LVEDA ratio significantly decreased postoperatively (0.97 ± 0.21 vs 1.19 ± 0.43, P = 0.002) and was correlated with ICI both in preoperative and postoperative periods (r = 0.57 and 0.57, respectively). There was a significant correlation between changes in RVEDA/LVEDA ratio and changes in total pulmonary resistance. CONCLUSIONS Improved ICI and RVEDA/LVEDA ratio reflected the surgical success of PEA and lowering of total pulmonary resistances. In contrast to the RV/left ventricular area ratio, annular RV indices associated poorly with postoperative ICI. Recognizing this limitation is important in minimizing the overdiagnosis of RV dysfunction after PEA.
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Affiliation(s)
| | - François Haddad
- Department of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Catherine Pilorge
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Myriam Amsallem
- Department of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - François Stéphan
- Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
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Yumoto T, Fujita T, Asaba S, Kanazawa S, Nishimatsu A, Yamanouchi H, Nakagawa S, Nagano O. Comparison of the ventilation characteristics in two adult oscillators: a lung model study. Intensive Care Med Exp 2019; 7:15. [PMID: 30868327 PMCID: PMC6419651 DOI: 10.1186/s40635-019-0229-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 02/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Two recent large randomized controlled trials did not show the superiority of high-frequency oscillatory ventilation (HFOV) in adults with ARDS. These two trials had differing results, and possible causes could be the different oscillators used and their different settings, including inspiratory time % (IT%). The aims of this study were to obtain basic data about the ventilation characteristics in two adult oscillators and to elucidate the effect of the oscillator and IT% on ventilation efficiency. METHODS The Metran R100 or SensorMedics 3100B was connected to an original lung model internally equipped with a simulated bronchial tree. The actual stroke volume (aSV) was measured with a flow sensor placed at the Y-piece. Carbon dioxide (CO2) was continuously insufflated into the lung model ([Formula: see text]CO2), and the partial pressure of CO2 (PCO2) in the lung model was monitored. Alveolar ventilation ([Formula: see text]A; L/min) was estimated as [Formula: see text]CO2 divided by the stabilized value of PCO2. [Formula: see text]A was evaluated with several stroke volume settings in the R100 (IT = 50%) or several airway pressure amplitude settings in the 3100B (IT = 33%, 50%) at a frequency of 6 and 8 Hz, a mean airway pressure of 25 cmH2O, and a bias flow of 30 L/min. Assuming that [Formula: see text]A = frequencya × aSVb, values of a and b were determined. Ventilation efficiency was calculated as [Formula: see text]A divided by actual minute ventilation. RESULTS The relationship between aSV and [Formula: see text]A or ventilation efficiency were different depending on the oscillator and IT%. The values of a and b were 0 < a < 1 and 1 < b < 2 and were different for three conditions at both frequencies. [Formula: see text]A and ventilation efficiency were highest with R100 (IT = 50%) and lowest with 3100B (IT = 33%) for high aSV ranges at both frequencies. CONCLUSIONS In this lung model study, ventilation characteristics were different depending on the oscillator and IT%. Ventilation efficiency was highest with R100 (IT = 50%) and lowest with 3100B (IT = 33%) for high aSV ranges.
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Affiliation(s)
- Tetsuya Yumoto
- Advanced Emergency and Critical Care Medical Center, Okayama University Hospital, 2-5-1, Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Takahisa Fujita
- Center for Innovative and Translational Medicine, Kochi University Medical School, 185-1, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Sunao Asaba
- Center for Innovative and Translational Medicine, Kochi University Medical School, 185-1, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Shunsuke Kanazawa
- Center for Innovative and Translational Medicine, Kochi University Medical School, 185-1, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Atsunori Nishimatsu
- Center for Innovative and Translational Medicine, Kochi University Medical School, 185-1, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Hideo Yamanouchi
- Department of Disaster and Emergency Medicine, Kochi University Medical School, 185-1, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Satoshi Nakagawa
- Department of Critical Care and Anesthesia, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Osamu Nagano
- Department of Disaster and Emergency Medicine, Kochi University Medical School, 185-1, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan.
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Mentzelopoulos SD, Anninos H, Malachias S, Zakynthinos SG. "Low-" versus "high"-frequency oscillation and right ventricular function in ARDS. A randomized crossover study. J Intensive Care 2018; 6:58. [PMID: 30202530 PMCID: PMC6122746 DOI: 10.1186/s40560-018-0327-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/22/2018] [Indexed: 11/10/2022] Open
Abstract
Background Recent, 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. Methods We 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. Results The 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). Conclusions In 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 registration This 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.
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Affiliation(s)
- Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodestrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, GR-10675 Athens, Greece
| | - Hector Anninos
- First Department of Intensive Care Medicine, National and Kapodestrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, GR-10675 Athens, Greece
| | - Sotirios Malachias
- First Department of Intensive Care Medicine, National and Kapodestrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, GR-10675 Athens, Greece
| | - Spyros G Zakynthinos
- First Department of Intensive Care Medicine, National and Kapodestrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, GR-10675 Athens, Greece
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Abstract
PURPOSE OF REVIEW In light of emerging data from clinical trials, the place of high-frequency oscillatory ventilation (HFOV) in the management of acute respiratory distress syndrome (ARDS) is uncertain. This review provides an overview of these new clinical data and also explores new areas of investigation for HFOV in adults. RECENT FINDINGS While prior meta-analyses suggested benefit for HFOV, updated systematic reviews published this year, which include two large recent clinical trials, now show no statistically significant impact of HFOV on mortality in adults with ARDS. It is possible that HFOV would be safer and more effective with a more individualized approach to setting mean airway pressure (mPaw). Possible techniques to achieve this include titrating mPaw in response to oxygenation or hemodynamic changes after HFOV initiation, by measuring respiratory system impedance, or by following echocardiographic changes. SUMMARY Although not first-line, HFOV remains a tool in the armamentarium of the intensivist managing the patient with severe ARDS and refractory hypoxemia. A refinement in the approach to delivering HFOV is warranted, with more attention paid to its adverse hemodynamic consequences.
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Klapsing P, Moerer O, Wende C, Herrmann P, Quintel M, Bleckmann A, Heuer JF. High-frequency oscillatory ventilation guided by transpulmonary pressure in acute respiratory syndrome: an experimental study in pigs. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:121. [PMID: 29743121 PMCID: PMC5943989 DOI: 10.1186/s13054-018-2028-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 04/05/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Recent clinical studies have not shown an overall benefit of high-frequency oscillatory ventilation (HFOV), possibly due to injurious or non-individualized HFOV settings. We compared conventional HFOV (HFOVcon) settings with HFOV settings based on mean transpulmonary pressures (PLmean) in an animal model of experimental acute respiratory distress syndrome (ARDS). METHODS ARDS was induced in eight pigs by intrabronchial installation of hydrochloric acid (0.1 N, pH 1.1; 2.5 ml/kg body weight). The animals were initially ventilated in volume-controlled mode with low tidal volumes (6 ml kg- 1) at three positive end-expiratory pressure (PEEP) levels (5, 10, 20 cmH2O) followed by HFOVcon and then HFOV PLmean each at PEEP 10 and 20. The continuous distending pressure (CDP) during HFOVcon was set at mean airway pressure plus 5 cmH2O. For HFOV PLmean it was set at mean PL plus 5 cmH2O. Baseline measurements were obtained before and after induction of ARDS under volume controlled ventilation with PEEP 5. The same measurements and computer tomography of the thorax were then performed under all ventilatory regimens at PEEP 10 and 20. RESULTS Cardiac output, stroke volume, mean arterial pressure and intrathoracic blood volume index were significantly higher during HFOV PLmean than during HFOVcon at PEEP 20. Lung density, total lung volume, and normally and poorly aerated lung areas were significantly greater during HFOVcon, while there was less over-aerated lung tissue in HFOV PLmean. The groups did not differ in oxygenation or extravascular lung water index. CONCLUSION HFOV PLmean is associated with less hemodynamic compromise and less pulmonary overdistension than HFOVcon. Despite the increase in non-ventilated lung areas, oxygenation improved with both regimens. An individualized approach with HFOV settings based on transpulmonary pressure could be a useful ventilatory strategy in patients with ARDS. Providing alveolar stabilization with HFOV while avoiding harmful distending pressures and pulmonary overdistension might be a key in the context of ventilator-induced lung injury.
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Affiliation(s)
- Philipp Klapsing
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Management, University Medical Center Göttingen, Göttingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Management, University Medical Center Göttingen, Göttingen, Germany
| | - Christoph Wende
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Management, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Herrmann
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Management, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Quintel
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Management, University Medical Center Göttingen, Göttingen, Germany
| | - Annalen Bleckmann
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Jan Florian Heuer
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Management, University Medical Center Göttingen, Göttingen, Germany. .,Department Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Management, Augusta-Kliniken Bochum-Mitte, Bochum, Germany.
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Guervilly C, Forel JM, Hraiech S, Roch A, Talmor D, Papazian L. Effect of high-frequency oscillatory ventilation on esophageal and transpulmonary pressures in moderate-to-severe acute respiratory distress syndrome. Ann Intensive Care 2016; 6:84. [PMID: 27577052 PMCID: PMC5005229 DOI: 10.1186/s13613-016-0181-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/10/2016] [Indexed: 12/02/2022] Open
Abstract
Background High-frequency oscillatory ventilation (HFOV) has not been shown to be beneficial in the management of moderate-to-severe acute respiratory distress syndrome (ARDS). There is uncertainty about the actual pressure applied into the lung during HFOV. We therefore performed a study to compare the transpulmonary pressure (PL) during conventional mechanical ventilation (CMV) and different levels of mean airway pressure (mPaw) during HFOV. Methods This is a prospective randomized crossover study in a university teaching hospital. An esophageal balloon catheter was used to measure esophageal pressures (Pes) at end inspiration and end expiration and to calculate PL. Measurements were taken during ventilation with CMV (CMVpre) after which patients were switched to HFOV with three 1-h different levels of mPaw set at +5, +10 and +15 cm H2O above the mean airway pressure measured during CMV. Patients were thereafter switched back to CMV (CMVpost). Results Ten patients with moderate-to-severe ARDS were included. We demonstrated a linear increase in Pes and PL with the increase in mPaw during HFOV. Contrary to CMV, PL was always positive during HFOV whatever the level of mPaw applied but not associated with improvement in oxygenation. We found significant correlations between mPaw and Pes. Conclusion HFOV with high level of mPaw increases transpulmonary pressures without improvement in oxygenation.
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Affiliation(s)
- Christophe Guervilly
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France.
| | - Jean-Marie Forel
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France
| | - Sami Hraiech
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France
| | - Antoine Roch
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France.,Service d'Accueil des Urgences, APHM, Hôpital Nord, Marseille, France
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, USA
| | - Laurent Papazian
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France
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