Dobyns Emily L, Anas Nick G, Fortenberry James D, Deshpande Jayvant, Cornfield David N, Tasker Robert C, Liu Paul, Eells Patricia L, Griebel Jeffery, Kinsella John P, Abman Steven H
Department of Pediatrics at the Children's Hospital University of Colorado School of Medicine, Denver, USA.
Crit Care Med. 2002 Nov;30(11):2425-9. doi: 10.1097/00003246-200211000-00004.
High-frequency oscillatory ventilation (HFOV) and inhaled nitric oxide (iNO) have been reported to improve oxygenation in children with acute hypoxemic respiratory failure (AHRF), but their roles in the treatment of AHRF remains unknown. The use of HFOV improves oxygenation by increasing lung recruitment. iNO can improve oxygenation in AHRF, but it may have limited efficacy in patients with poor lung inflation. Based on these findings, we hypothesized that the combined treatment of HFOV and inhalation of low-dose NO would improve oxygenation and survival in children with severe AHRF compared with children treated with conventional mechanical ventilation (CMV) or either treatment alone.
Tertiary pediatric intensive care units at seven academic centers.
Post hoc analysis of data from children enrolled in a multicenter, randomized, masked study of the use of iNO in the treatment of AHRF.
A total of 108 pediatric patients with AHRF defined as an oxygenation index of >15 twice within 6 hrs. Mode of ventilation (HFOV or CMV) was determined by the patient's physician based on guidelines to maximize oxygenation. The patient was then randomized to treatment with or without iNO. Comparisons were made between patients who were treated with HFOV plus iNO (n = 14), HFOV alone (n = 12), CMV plus iNO (n = 35), and CMV alone (n = 38).
Ventilation with CMV or HFOV with or without iNO.
We found that the change in Pao /Fio ratio was greatest in the HFOV plus iNO group compared with the other treatment groups at 4 hrs (p =.02) and 12 hrs (p =.01). After 24 hrs of treatment, both HFOV plus iNO and HFOV alone resulted in greater improvement in Pao2/Fio2 ratio than either CMV alone or CMV plus iNO (p =.005). After 72 hrs, treatment with HFOV alone resulted in a greater improvement in Pao2/Fio2 ratio than either CMV alone or CMV plus iNO (p =.03). There was no difference in predefined treatment failures between treatment groups.
We conclude that the combination of HFOV with iNO causes a greater improvement in oxygenation than either treatment strategy alone in children with severe AHRF. We speculate that the enhanced lung recruitment by HFOV enhances the effects of low dose iNO on gas exchange.
据报道，高频振荡通气（HFOV）和吸入一氧化氮（iNO）可改善急性低氧性呼吸衰竭（AHRF）患儿的氧合，但它们在AHRF治疗中的作用仍不明确。HFOV通过增加肺复张来改善氧合。iNO可改善AHRF患儿的氧合，但对肺膨胀不良的患者可能疗效有限。基于这些发现，我们推测与接受传统机械通气（CMV）或单独使用这两种治疗方法之一的患儿相比，联合使用HFOV和吸入低剂量NO治疗可改善重度AHRF患儿的氧合及生存率。
七个学术中心的三级儿科重症监护病房。
对参加一项关于iNO治疗AHRF的多中心、随机、盲法研究的患儿数据进行事后分析。
共有108例AHRF患儿，定义为在6小时内氧合指数>15两次。通气模式（HFOV或CMV）由患儿的医生根据指南确定，以最大限度地提高氧合。然后将患者随机分为接受或不接受iNO治疗。对接受HFOV加iNO治疗的患者（n = 14）、单独接受HFOV治疗的患者（n = 12）、CMV加iNO治疗的患者（n = 35）和单独接受CMV治疗的患者（n = 38）进行比较。
使用CMV或HFOV通气，加或不加iNO。
我们发现，与其他治疗组相比，HFOV加iNO组在4小时（p = 0.02）和12小时（p = 0.01）时Pao₂/Fio₂比值的变化最大。治疗24小时后，HFOV加iNO组和单独使用HFOV组的Pao₂/Fio₂比值改善程度均大于单独使用CMV组或CMV加iNO组（p = 0.005）。72小时后，单独使用HFOV治疗的患者Pao₂/Fio₂比值的改善程度大于单独使用CMV组或CMV加iNO组（p = 0.03）。各治疗组之间在预定义的治疗失败方面没有差异。
我们得出结论，在重度AHRF患儿中，HFOV与iNO联合使用比单独使用任何一种治疗策略能更大程度地改善氧合。我们推测HFOV增强的肺复张作用增强了低剂量iNO对气体交换的影响。
